Membership Form

Membership Form

P.O.Box HM2346

www.bermudabasketball.net

Membership fee per person: $25.00

Athlete/Parental Information

Player Name*

First NameLast Name

Date of birth*

mm/dd/yyyy

Are you over 18 ?*

YesNo

Guardian / Parents Names

First NameLast Name

Signature

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail*

Are you Interested in Volunteering?

yesno

Emergency Contact & Health Insurance Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Do you have health insurance ?

YesNo

Do you have any allergies, chronic illness, or medical conditions that would limit high level activtiy?*

YesNo

Please describe

Parental Permission For Emergency Treatment

In the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to take my child to: K.E.M.H.
I give consent for the facility to secure any and all necessary emergency medical care for my child.

Release of Liability

Although the safety of all sport activities is the primary concern, indoor sport activities may cause injuries and/or death. I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against the Bermuda Basketball Association and the persons in charge.

please add photo:

Upload a File

I have read and agree to the above conditions*

YesNo

Confirmation E-mail*

Signature*

Enter the message as it's shown*

All payments can be made via direct deposit to our BNTB account. Please note team name and event.

A/c #0604015350013

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 bermudabasketball@gmail.com .