JGTBA 2016-17 Registration Form
PLAYER
INFORMATION
Player Name
Street Address
City
Cell Phone
Age
Grade (Fall 2015)
School
Parent(s) Name(s)
Zip
PARENT
INFORMATION
Home Phone
Cell Phone
Email Address
I acknowledge that my child resides within the Jefferson High School attendance area or that I
will obtain a waiver from the traveling basketball association for the school attendance area
which my child resides.
I understand parent(s) are required to work a minimum of 4 hours during the JGTBA home
tournament January 29th - 31st, 2016 and a 3-on-3 event in spring. More information to follow
as tournament gets closer via team representative.
VOLUNTEER
Please mark the position(s) you are interested in.
Coach
Parent Signature:
Asst. Coach
Team Rep.
Other Volunteer
Date:
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PARENTS COMMITMENT
As a parent representing the Jefferson Girls Traveling Basketball Association, I affirm my
commitment to the following:
1. I will demonstrate a positive attitude toward coaches, game officials, players and other
parents on the team.
2. I will treat our opponents (players, coaches and parents) with respect.
3. I will address ANY concerns regarding game or practice participation with the coach first.
4. All concerns regarding officiating and fair play will be taken up with my team’s coaches
only.
5. I will make every effort to assist my daughter in attending practices and games on time.
6. I understand there may consequences if my daughter is tardy or missing practices or
games and may result in her not being able to play in a game.
7. I understand I (including my spouse) am required to work one shift (minimum of 4
hours) for each child I have participating in the JGTBA tournaments.
8. I will help my daughter understand the values needed in a successful team sport. Among
them are the following:
a. Unselfishness
b. Fair play and sportsmanship
c. Sense of team play
d. Emotional support of teammates
e. Positive attitude
f. Respect for coaches
Parent Signature
Date
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PLAYERS COMMITMENT
As a Player representing the Jefferson Girls Traveling Basketball Association, I affirm my
commitment to the following:
1. I will be coachable. I will listen to my coach’s direction and comments willingly and make
every effort to improve myself.
2. I will be, first and foremost, a team player dedicated to a spirit of oneness and helping
others feel a sense of belonging.
3. I will be a positive role model for younger players.
4. I will practice with the same effort and determination as in a game. I will realize that
practice requires hard work and sweat.
5. I will be on time to all practices and games.
6. I understand there may consequences to being tardy or missing practices or games and
may result in me not being able to play in a game.
7. I will make every attempt to arrange my schedule as to not interfere with practices and
games.
8. I will treat other players, coaches, fans and officials with respect regardless of race, sex,
creed or ability.
9. I will accept my coach’s decisions as final. If I disagree with my coach, I will talk with him/her
privately and with respect.
10. I will adhere to the policies of JGTBA regarding the use of tobacco, alcohol and all
controlled substances. I will also report use by others to my coach and/or parents.
11. I will believe in myself and will play with confidence. I will not let the fear or failure hold
me back or dwell on my mistakes.
12. I will have fun!
Player Signature
Date
RELEASE AND WAIVER OF CLAIMS
The undersigned parent(s) or legal guardian(s) of
(print), a minor, recognize the inherent
risks of injury to youths participating in the Jefferson Girls Traveling Basketball Program. I/We agree on behalf of
ourselves and for the minor child, that the coaches, The Jefferson Girls Traveling Basketball Program and its
officials, schools participating in the league, referee, and any party connected with the Jefferson Girls Traveling
Basketball Program shall not be held responsible or liable for any negligence, implied or otherwise, or any manner
of personal injury, property damage or loss suffered or sustained during any tryout, game, practice, tournament or
team activity; including, but not limited to, transportation to or from any game, practice, or team activity during the
2016-17 traveling basketball season. I/We further hereby agree not to sue, or bring any claims, demands, or
causes of damage of any kind whatsoever against the persons and entities listed above, arising out of, or
connected with, any personal injury, death or property damage or during any tryout, game, practice, tournament or
team activity; including, but not limited to, transportation to or from any game, practice or team activity during the
2016-17 traveling basketball season. This waiver also applies to any dental injuries incurred while participating in
traveling basketball. Mouth guard protection is highly recommended for all participants in the Jefferson Girls
Traveling Basketball Program. It is my/our express intent and purpose to bind myself, my heirs, executors,
administrators and assigns by this RELEASE AND WAIVER OF CLAIMS.
Notwithstanding anything set forth above, this RELEASE AND WAIVER OF CLAIMS shall not apply to intentional
torts committed by those persons and parties referred to above.
I/We further certify that the player named above is in good physical condition, and has no known medical or other
problem which would prevent the player from actively participating in all activities associated with the Jefferson
Girls Traveling Basketball Team.
I/We certify that I/We have carefully read the full text of this RELEASE AND WAIVER OF CLAIMS prior to signing,
and that I/We fully understand and agree to its terms.
Parent/Guardian Name:
Parent/Guardian Signature:
Address:
Date:
City:
Home Phone Number:
Work Phone Number:
Other Number
Players Birth date:
Comments, conditions, illnesses, situations we should be aware of:
Zip:
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MEDICAL INFORMATION AND ASSIGNMENT FORM
The undersigned, being the parent(s) and or sole legal guardians of
, a minor, do
hereby constitute and authorize my daughter’s team Coach, Assistant Coach or Parent Representative together
with all other medical, hospital and emergency personnel to carry out and institute all treatment and diagnosis in
situations where it would be impractical or impossible based upon the circumstances, to obtain additional timely
consent.
Parent/Guardian Signature
Date
Health Insurance Company Policy Number/Contract Number:
Player’s Physician:
Physician Phone Number:
Player’s Dentist:
Dentist Phone Number:
Please list any medication taken on a regular basis, including dosage and reason for medication. (Include allergy
shots and dates given):
Please list any allergy and player’s reaction:
Does your player wear contacts?
Does your player wear glasses?
YES
NO
YES
NO