Player Name
Birth Date
Girls or Boys age on Sep 1, 2012
Gender	Male Female
	Only brand new Renegades need to fill in UNIFORM info below:
Adult Shirt Size	Small Medium Large X-Large XX-Large
Adult Short Size	Small Medium Large X-Large XX-Large
Uniform # Request - Top 5 picks:	-->
Previous Experience
Height (nust be entered)
School
Grade (2011/12 School Year)
Player Street Address
Address (cont.)
City
State
County
Zip/Postal Code
Mother's Name
Father's Name
Cell Phone
Home Phone
Parent's E-mail (Club Use Only)
EmergencyContact
Emergency Phone
Dr.'s Name/Phone
Health Ins Co Name
Health Ins Co ID#

Participants Medical History & Permission Statement - Must be completed by Parent or Guardian

 

Has your child ever been treated by a Doctor for, or experienced, any of the following?  Please check Yes or No:

Head Injury: No   Yes	Concussion:  No   Yes	Dizzy Spells: No    Yes
Asthma:    No   Yes	Fainting: No   Yes	Anemia: No    Yes
Back Injury:  No   Yes	Diabetes:   No   Yes	Fatigue: No    Yes
Heart Problem: No   Yes

 

Is your child allergic to any drugs, serums, adhesive tapes or insects?

Drug Allergy No    Yes

Please explain:

Is your child allergic to any food or other substances?

Food Allergy No    Yes

 

 Please explain:

Has your child ever been told not to participate in sports because of a health problem?

Health Problem No    Yes

 

Please explain:

Does your child take medication regularly?

Medication No    Yes

 

Please list medications:

 

Has your child had any serious illness or operation in the past year?

Operation No    Yes

 

Please explain:

 

Is your child currently under a Doctor's care?

Doctor Care No    Yes

 

Please explain:

Is there any medical condition that would limit your child's participation in our program?

Medical Condition No    Yes

 

Please explain:

 

 

 

(Player's Name) has my permission to participate in the Renegades Basketball program.  I hereby assume all risks associated with the participation of my child in the Renegades Basketball program and agree to hold harmless the Renegades organization, its officers, coaches, and participants for any and all claims for injuries arising out of participation in this program.  I have completed and understand the details of this form and attest to its accuracy.  I certify that my child has primary health insurance with the above carrier.  I also give permission for my child to be examined and treated by a physician in case of emergency.

 

Important info for brand new Renegades’ members joining 9-1-11 thru Spring 2012: During the fall/winter of 2004 the Renegades Organization built a brand new 3 court facility inside a warehouse at 2950 Turnpike Dr., Hatboro, PA. All Renegades’ families at that time either procured $500.00 worth of advertising sponsorships from local businesses or contributed a personal tax deductible donation in that amount. All brand new members that register with the club on September 1, 2011 thru the spring of 2012 will not be responsible for this obligation during their first year of participation with the Renegades. However, if you choose to re-register for your second year with us the following September 1st, 2012, then the building fund sponsorship/contribution of $500 will be due but payment can be spread out over a 4 year period. So for all those families that are re-registering for a second year with us on Sept 1, 2012 or later, the $125.00 yearly donation will be due on Feb 1, 2013 and needs to be paid prior to the player participating in 2013 spring aau evaluations. Or you have the option of obtaining a yearly business sponsorship of $125.00 per year for 4 years.
I have read and understand the above paragraph about the gym fundraising campaign.  

 

 

Signature (Parent / Guardian):   Date:  

 

 

Checks made out to: Renegades Basketball

Mail to: Renegades Basketball 858 Street Road, Southampton, PA  18966 or Register Online