IMPACT Basketball – Travel Team
Try Out Number
REGISTRATION FORM
____________________
PAID
Print all the information requested below.
____________________
Today’s Date:
Participant #1 Name:
☐ Male ☐ Female
Birthdate
School Attending
City
Previously played for IMPACT before?
T-Shirt Size:
Youth / Adult (circle one)
☐ Yes ☐ No
☐
X-Small
Grade Level
If yes, what years?
☐
Small
☐
Medium
☐
☐
Large
X-Large
Participant #2 Name:
☐ Male ☐ Female
Birthdate
School Attending
City
Previously played for IMPACT before?
☐ Yes ☐ No
Grade Level
If yes, what years?
T-Shirt Size:
Youth / Adult (circle one)
☐
X-Small
☐
Small
☐
Medium
☐
Large
☐
X-Large
Guardian #1
Information
☐
Mother
☐
Father
☐
Step
parent
☐
Grandparent
☐
Other
Guardian #1 Name
Address
City/State/Zip
Guardian #1 Home Ph#:
Guardian #1 Cell Ph#:
Guardian #1 Work Ph#:
Guardian #1 Email:
☐
Guardian #2 Information
Mother
☐
Father
☐
Step
parent
☐
Grandparent
☐
Other
Guardian #2 Name
Address
Guardian #2 Home
Ph#:
City/State/Zip
Guardian #2 Cell Ph#:
Guardian #2 Work Ph#:
How did you hear about
IMPACT?
Guardian #2 Email:
☐ Friend ☐ Parent ☐ School ☐ Coach Referral ☐ Newspaper Ad ☐ Flyer/Brochure ☐ Email ☐ Other
I hereby consent to my child’s participation in IMPACT basketball skills and development program. I understand that
participation in these activities can result in injuries, and I accept that risk. I hereby release, indemnify, and hold harmless
IMPACT Basketball, including it agents, directors, drivers, coordinators, managers, and coaches from any and all claims
arising out of injury and harm to my child as a result of his/her participation in the aforementioned basketball program and
related activities.
Date:
Signature:
IMPACT ADMINISTRATION ONLY:
Amt Paid: $
☐
Cash
☐
Check #
☐
Other