Basketball and Cheerleading Registration

Fairfield Baptist Church Recreation Ministry
Basketball and Cheerleader Registration

Child's Information

Which activity will your child be participating?

Cheerleading - Fee is $125.00

Girls Basketball - Fee is $85.00

Boys Basketball - Fee is $85.00

School Player- (If Yes, he or she cannot participate in this league.)

Yes

First Name

Address, City, State, Zip code

Date of Birth

Please Upload your child's birth certificate

ADD FILE

Please upload a recent photo (you may use your cell phone)

ADD FILE

Uniform Information: Jersey (Top)

Youth Small

Youth Medium

Youth Large

Youth Extra Large

Adult Small

Adult Medium

Adult Large

Adult Extra Large

Uniform Information: Shorts (Bottoms)

Youth Small

Youth Medium

Youth Large

Youth Extra Large

Adult Small

Adult Medium

Adult Large

Adult Extra Large

Parent Information

Parent or Guardian First and Last Name

Parent or Guardian Cellphone Number

Parent or Guardian Email Address

Which form(s) of communication do you authorize? (Check all that applies)

Phone Call

Text Messages

Parent or Guardian First and Last Name

Parent's Cellphone Number (second parent)

Parent or Guardian Email Address

Which form(s) of communication do you authorize? (Check all that applies)

Phone Call

Text Messages

Do you give permission for your child's photo to be used for any lawful purpose, including publicity, illustration, advertising, and web content?

Yes

Medical and Emergency Information

If the answer is YES to any medical questions you MUST complete the additional MEDICAL FORM.

Does your child have an illness that requires medication?

Is there special health information that we should know about your child?

Does your child have any food allergies, or is he or she allergic to any medications?

What is the date of your child's last physical exam

Please provide name, address and phone number of your child's primary care physician.

Who is your child's healthcare provider?

Waiver and Hold Harmless Agreement

Do you understand and consent to the Waiver and Hold Harmless Agreement Part 1?

Yes

No - Child Cannot Participate

As the parent or guardian of said child, I hereby give permission for my child to participate in the athletic program sponsored by the Micheal Benton Family Life Center, Inc. and the United Christian Athletic Association (UCAA). I understand that Micheal Benton Family Life Center, Inc., is a subsidiary of the Fairfield Baptist Church. The Micheal Benton Family Life Center, Inc. and the United Christian Athletic Association are non-profit charitable institutions, which are voluntarily presenting the basketball and cheerleader programs for my child, other participants, and the community. In consideration of giving my permission for my child to participate in the program this season (hereby called the (“COMPETITION”), which is organized by the Micheal Benton Family Life Center, Inc., and the United Christian Athletic Association, I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE TO HOLD HARMLESS for any and all purposes the Micheal Benton Family Life Center, Inc., the Fairfield Baptist Church, the United Christian Athletic Association, and each and every organization involved with sponsoring the COMPETITION, and their officers, directors, agents, volunteers, or employees (hereby collectively called the (“ORGANIZERS”) FROM ANY AND ALL LIABILITIES, CLAIMS, DEMANDS, DAMAGE TO PROPERTY, OR PERSONAL INJURY that may be sustained as a result of my child’s participation in the COMPETITION or the use of equipment or facilities provided by the ORGANIZERS. I also understand that my child is participating in an active sport, which can involve physical contact with other members, the floor, field, or equipment, and that there is a resulting risk of physical injury to my child. I have explained these risks and the benefits of participating in sports to my child and my child is in proper physical condition. My child does not have any existing injuries or conditions that could jeopardize his or her safety or health of the other participants.

Do you understand and consent to the Waiver and Hold Harmless Agreement Part 2?

Yes

No - Child Cannot Participate

My child’s participation in COMPETITION and its associated activities and events is completely voluntary at our own risk. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY that may be sustained during or as a result of his or her participation in the COMPETITION and its associated activities and events, WHETHER CAUSED BY AN ACT OF COMMISSION OR OMISSION on the part of the ORGANIZERS or otherwise. I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS the ORGANIZERS for any loss, liability, damage or costs that may occur as a result of my child’s participation in the COMPETITION and its associated activities and events. It is my express intent that this CONVENANT NOT TO SUE AND HOLD HARMLESS agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased.In checking “YES” to this COVENANT NOT TO SUE and HOLD HARMLESS agreement, I acknowledge and represent that I have read the foregoing COVENANT NOT TO SUE and HOLD HARMLESS agreements, understands it, and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements apart from the foregoing agreement that has been reduced to writing have been made. I execute this document for full, adequate and complete consideration fully intending to be bound by the same, now and in the future.I/we the undersigned, being a parent or guardian of the minor listed above and having legal capacity to act on her behalf, do hereby consent to the foregoing HOLD HARMLESS AGREEMENT.

Payment

http://paypal.me/FBCbballCheer Payment

Option 1