2011 South Shore Patriots AAU Basketball Registration Form
Please print this form. Circle Division 12U 13U 14U 15U 16U
Player’s Name__________________________________________________________________
First Middle Last
Address_________________________________City_____________________Zip___________
Phone:___________________________Email:________________________________________
Fathers Cell___________________________Mothers cell_____________________________
Fathers Name_________________________ Mothers Name__________________________
Current Grade_____________________ Age__________ D.O.B._________________________
School Attending_______________________________________________________________
Waiver / Release
I, hereby, waive, release and hold harmless the South Shore Patriots organization, directors,
coaches, volunteers, and organizers from any liability for injury, illness, problems or accidents
that may occur to my child/guardian.
____________________________________________________(child’s name) while
participating in this program. I am aware that basketball is a contact sport and an injury
is a potential risk inherent to the game. I will not seek damages against South Shore Patriots,
it’s members, directors, coaches, volunteers or against Halifax Elementrary School,
Marshfield High School, Duxbury High School, Jacob Elementary School, Sacred Heart high school
if such accident or injury occurs.
I give permission for emergency medical treatment in the event I cannot be reached.
Parent signature for waiver__________________________________Date__________________
Player medical plan______________________________Medical Ins.#_____________________
Players Physician______________________________Phone____________________________