Player Name
Gender:	Girl   Boy
Birthdate:
Height:
Address
City
State
Zip Code
Mom Cell Phone
Mom Name
Dad Name
Dad Cell Phone
Home Phone
E-mail

Adult Shirt Size

Small Medium Large X-Large XX-Large

School Grade 2011	SELECT 4th 5th 6th 7th 8th 9th 10th 11th 12th
Players School

What position does child play? (Please check)   Guard  Forward

Please describe player's bball experience yrs. AAU, Travel etc?
List a few friends you would like on team if possible:

PARENTAL PERMISSION

My child has my permission to participate in the 2011 John Walker Memorial Fall League.  I hereby assume all risks associated with the participation of my child in the Renegades Program, and agree to hold harmless the Renegades AAU organization, their officers, coaches, and participants for any and all claims or injuries arising out of participation in the Renegades program. I have completed and understand the details of this form and attest to its accuracy.

All persons are required to be covered by a personal or family medical plan including hospitalization before they can participate in the program.

I certify that the person named above is covered by such a plan.

I the undersigned parent (legal guardian), do hereby grant permission to any licensed physician to perform or provide necessary medical care or aid to my child or ward who was injured in connection to the playing of basketball.

(signature)(date) 

Any player who does not play AAU basketball or plays AAU basketball with another club needs to register online at: aausports.org.  When you register online, you must check off AB (added benefit) and you will be covered under the AAU supplemental insurance from 8/16/11 to 8/31/12. This aausports.org insurance is not available until August 16^th. This insurance covers the player not only for basketball but for any sport that the player participates in during the entire year and is well worth the $14.00.   

Non-Renegade players only need to pay the $130 Walker League fee + purchase 2011/2012 AAU Insurance as specified above.  Renegade players need to also send in their annual re-registration club membership form and fee.  AAU insurance is included in your annual Renegades club registration fee.

Checks payable to:  Renegades, 858 Street Rd., Southampton, PA 18966 (mailing address)

Please send reg form and $130.00 payment by deadline of 8-19-11. (Add 25.00 late fee after 8-19-11)