Clone of Chi-ball Y league Registration Form

Cheer/Dance & Basketball Registration Form

For cheer, dance, and basketball participants

10355 S Woodlawn, Chicago, IL 60628
Athlete / Participant Information
Participant Name

First NameLast Name
Are you the parent or guardian of the participant you are registering?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian / Parent Name

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail

Basketball / Cheer-Dance skill level

	1	2	3	4	5

1 is Beginner, 5 is Advanced

Interested in Volunteering while your team not playing?
Emergency Contact & Health Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Do you have health insurance ?
Insurance Carrier
Name of Policy Holder
Subscriver ID/Group Number
Card Number / Card Date
Does you have any allergies, chronic illness, or medical conditions that would limit high level activtiy?
Please describe
Permission for Emergency Treatment

In the event of illness or accident, I give permission for emergency treatment by qualified medical personnel for my child or participant, and I authorize the person in charge to take my child to:
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Name of Physician / Emergency Medical Care Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Release of Liability

Although the safety of all activities is the primary concern, cheer, dance, and basketball participation may involve risk of injury, death, or illness. I expressly assume those risks and agree to waive the right to pursue any claim against the Youth Sport Center and the persons in charge.
I have read and agree to the above conditions
Confirmation E-mail
After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at chiballyleague@gmail.com
Cheer/Dance & Basketball Registration

Complete this form to register for cheer, dance, or basketball activities.
Email
example@example.com
Phone Number

Area CodePhone Number
Birth Certificate

Browse Files

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