Name: Junior Premier Program Registration
SKU: JRCAVS-16
Price: 100.00 USD
Availability: InStock

Registering Parent/Guardian

Primary Parent/Guardian Full Name *

Cell Phone *

Home Address

City

State/Province

Zip/Postal

Email *

Current Employer

Business Phone

Would your employer be interested in being a team sponsor for our program?

Yes

No

Employer Contact Name and Number

Click the Add button below to enter information for an additional parent or guardian.

Add Remove

Confirm the number of participants you are registering: *

Participant

You must be legal parent/guardian to register participants.

School Child Attends *

Current Grade Level * Current Grade Level

Child's First Name *

Last Name *

Date of Birth

Age

Check all that apply and list details below:

Medical/Health Needs

Medications

Allergies

Dietary Restrictions

Medical/Health Needs

Medications

NOTE: A medication form must be completed for each medication to be administered during the program.

Allergies and Treatments

Dietary Restrictions

Participant 2

You must be legal parent/guardian to register participants.

School Child Attends *

Current Grade Level *

Child's First Name *

Last Name *

Date of Birth

Check all that apply and list details below:

Medical/Health Needs

Medications

Allergies

Dietary Restrictions

Medical/Health Needs

Medications

NOTE: A medication form must be completed for each medication to be administered during the program.

Allergies and Treatments

Dietary Restrictions

Participant 3

You must be legal parent/guardian to register participants.

School Child Attends *

Current Grade Level *

Child's First Name *

Last Name *

Date of Birth

Check all that apply and list details below:

Medical/Health Needs

Medications

Allergies

Dietary Restrictions

Medical/Health Needs

Medications

NOTE: A medication form must be completed for each medication to be administered during the program.

Allergies and Treatments

Dietary Restrictions

Participant 4

You must be legal parent/guardian to register participants.

School Child Attends *

Current Grade Level *

Child's First Name *

Last Name *

Date of Birth

Check all that apply and list details below:

Medical/Health Needs

Medications

Allergies

Dietary Restrictions

Medical/Health Needs

Medications

NOTE: A medication form must be completed for each medication to be administered during the program.

Allergies and Treatments

Dietary Restrictions

Emergency Contacts

Please list three authorized persons (other than parents/guardians) to take child from the program in the event of an emergency.

Name *

Relationship *

Primary Phone *

Name *

Relationship *

Phone *

Authorization

League Fee, Refund and Cancellation Policy

Discounted cost for participation is $100 for remainder of season. These fees are non-refundable, even in the event of cancellation, and must be paid at the time of sign-up. Checking the box below indicates that you accept the terms specified in this policy.

League Fee Policy *

I accept

Release of Liability & Permission to Secure Treatment

I recognize and acknowledge that there are certain risks of physical injury to participants in the above program(s) and I agree to assume the full risk of any injuries, damages or loss regardless of severity which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with such program(s).

I agree to waive and relinquish all claims I or my minor child/ward may have against the Central Ohio Junior Premier Basketball League, COPLAY and their affiliates, officers, agents, volunteers, employees and any companies associated as a result of participation in the program.

I do hereby fully release and discharge the Central Ohio Junior Premier Basketball League, COPLAY and their affiliates officers, agents, volunteers and employees from any and all claims from injury, damage or loss with the activities of the program(s).

I further agree to indemnify and hold harmless and defend and its officers, agents, servants and employees from any and all claims resulting from injuries, damages, and losses sustained by me or my minor child arising out of, connected with, or in any way associated with the activities of the program(s).

In the event of any emergency, I authorize the Central Ohio Junior Premier Basketball League to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for me or my minor child/ward's immediate care and agree that I will be responsible for payment of any and all medical services rendered.

Therapeutic Behavior Group Services which includes skills development of interpersonal and social competency, confidence building along with emotional and behavior management while participating in sports are inclusive with participation in the Central Ohio Junior Premier Basketball League.

Checking the box below indicates that you accept the terms specified in this agreement (click to view).

Liability Waiver *

I accept

Insurance/Health Plan

Policy Number

Photos and Videos

Checking the box below indicates that you accept the terms specified in this agreement.

I give the Central Ohio Junior Premier Basketball League permission to use my child's picture or videos that include my child for promotional purposes.

Photo and Video Release *

I accept

Authorized by (enter your name) *

Primary Parent/Guardian Full Name *

DO NOT adjust quantity with button below. Quantity should be 1. Cost is adjusted based on the number of participants confirmed on the form above.

Paragraph Text

Junior Premier Program Registration

JUNIOR PREMIER Youth Basketball & CHEER Program

Registering Parent/Guardian

Participant

Participant 2

Participant 3

Participant 4

Emergency Contacts

Authorization

League Fee, Refund and Cancellation Policy

Release of Liability & Permission to Secure Treatment

Photos and Videos

Donations and Payments

Summer Program Registration Fee

Junior Premier Program Registration

JUNIOR PREMIER Youth Basketball & CHEER Program

Registering Parent/Guardian

Participant

Participant 2

Participant 3

Participant 4

Emergency Contacts

Authorization

League Fee, Refund and Cancellation Policy

Release of Liability & Permission to Secure Treatment

Photos and Videos

Related products

Donations and Payments

Summer Program Registration Fee