BASKETBALL

CC Panthers Inc. Basketball Registration Form

$115

Early Bird Basketball Registration Until 11/15

$135

Basketball Registration After 11/15

Sport Application Information

Player Name (First, Middle, Last)

Date of Birth

Parent/Guardian Name (First, Middle, Last)

Address

Phone

Emergency Contact Information

Name of Emergency Contact(s) (First, Middle, Last)

Phone Number

Address

Relation to Athlete

I hereby declare that I give my full express consent to let my child be given immediate treatment by any qualified medical personnel in circumstances which may need immediate attendance and care.

Medical Information

In case the parent/guardian is out of reach at the time of emergency, with consent of the latter, we will exercise the required diligence needed to have the athlete treated by an E.R Physician. In this regard, we would like to get to know any precautions that we need for the athlete.

Clinic/Hospital

Name of Family Doctor

Any Allergies to Medicine and Antibiotics? Required

Yes

If Yes, Please List Any Allergies to Medicine to Antibiotics:

Medical Diagnosis:

Medicine Taken

Dosage

Dosage/Frequency Taken

Parental/Guardian Consent

I am aware that any physical sport activity may cause accidental injury or harm among the athletes, and I assume any and all possible risk that may cause injury, illness, or death arising to such activity. I agree to waive my right to pursue any claim against the Commission and the Organizing Committee of this event.

Your Signature

Parent/Guardian Name(s)

This will take you to an external site to continue registration.

CC Panthers Inc. Basketball Registration Form​