Membership Form

Membership Form

P.O.Box HM2346

www.bermudabasketball.net

Membership fee per person: $25.00

Team Registration Fee: $1600
Athlete/Parental Information
Player Name *

First Name Last Name
Date of birth *
mm/dd/yyyy
Are you over 18 ? *

Yes No
Guardian / Parents Names

First Name Last Name
Signature
Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
E-mail *

Basketball skill level *

	1	2	3	4	5

1 is Beginner, 5 is Advanced

Interested in Volunteering while your team's not playing?

Match Referee score table shot clock
Important Notes

· Dress appropriately.

· No food or drink in the gym.

· Keep the gym clean.

· Membership Fee: $25 per participant.
Emergency Contact & Health Insurance Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Do you have health insurance ?

Yes No
Does you have any allergies, chronic illness, or medical conditions that would limit high level activtiy? *

Yes No
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:
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:
I have read and agree to the above conditions *

Yes No
Confirmation E-mail *
Signature *

Clear
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 as benificiary.

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 .
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Release of Liability