Li'l Dribblers Basketball Clinic Registration - Valley Jewish Community Center

Li’l Dribblers Basketball Clinic Registration

Please fill in the form below for each child you would like to register for Li’l Dribblers Basketball Academy.

"*" indicates required fields

Name*

First Last

Date of Birth*

T-Shirt Size*

Grade*

School Name*

Parent 1 Name*

First Last

Parent 1 Phone*

Parent 1 Email*

Parent 2 Name

First Last

Parent 2 Phone

Parent 2 Email

Medical Insurance Carrier:*

Primary Policy Holder Name*

First Last

Policy Number/ID*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Comments/Requests

Registration Fee

Includes T-Shirt and Basketball

Price:

3% Processing Fee

Price: $0.00

Total

Includes registration fee plus 3% credit card processing fee.

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

PARENT PERMISSION FORM, LIABILITY WAIVER AND RELEASE, AND AUTHORIZATION FOR MEDICAL/DENTAL TREATMENT I understand that participation in the are you VJCC/Valley Stars Basketball Academy involves risk and dangers of serious and permanent bodily injury and death. I hereby release, hold harmless, discharge and agree not to sue Valley Stars Basketball Academy, the VJCC, all their affiliates and DBA, all directors, officers, employees, coaches, officials, volunteers, owners/leasers of premises for and from all liability from my participation in and with these and any other related travel, lodging, social and recreational activities. I also understand Valley Stars Basketball Academy retains the right to use for publicity and advertising, photographs and video taken of the participants. I have given my son/daughter permission to participate in the VJCC/Valley Stars Basketball Academy programs, and I certify that he is in good health, has been cleared by a physician and can take part in all physical activities not limited to, but including training, practices, and games. I am aware that my son/daughter may become injured. If an injury occurs, I authorize the staff members to take any action and use the emergency service available at the nearest hospital if necessary. I understand my personal insurance will be used in this case. In case of an emergency, I authorize the personnel to take action.

Name*

First Last

By typing your name below you are indicating you have read the above Parent Permission form, liability waiver, and release.

Medical Release**

I, the undersigned, the parent and/or legal guardian of the child listed below (Player) hereby grant permission for the VJCC/Valley Stars Basketball Academy, its officers, employees, and coaches to authorize medical or dental treatment for the Player by any available and qualified physician/dentist or other trained medical personnel. In addition, this permission extends to and includes authorization for emergency treatments, procedures, and surgeries for the player. Furthermore, on-going medical treatment is authorized until such time as the undersigned shall dismiss these physicians/medical personnel in writing and have engaged another qualified physician. This permission and authorization includes admission to a hospital or medical facility if the attending physician deems it necessary.

Player Name*

First Last

By typing your name below you are indicating you have read the above Parent Permission form, liability waiver, and release.

Parents Code of Conduct**

I have read and agree to abide by the VJCC Parents Code of Conduct and fully understand its contents. By checking the box to the left, I am agreeing to the terms and conditions stated within and acknowledge that this will serve as my electronic signature.

Waiver**

I have carefully read the Valley Jewish Community Center Waiver and Release of Liability and fully understand its contents. By checking the box to the left, I am agreeing to the terms and conditions stated within and acknowledge that this will serve as my electronic signature.

Please click the submit button only once to avoid duplicate charges / submissions. Sometimes it takes a minute or two to process.

This field is for validation purposes and should be left unchanged.

Valley Jewish Community Center

Li’l Dribblers Basketball Clinic Registration

Valley Jewish Community Center
18017 Chatsworth St. # 217, Granada Hills, CA 91344
818-360-2211 • info@valleyjcc.org

NEWSLETTER SIGN UP

Li’l Dribblers Basketball Clinic Registration

Valley Jewish Community Center18017 Chatsworth St. # 217, Granada Hills, CA 91344818-360-2211 • info@valleyjcc.org

NEWSLETTER SIGN UP

Valley Jewish Community Center
18017 Chatsworth St. # 217, Granada Hills, CA 91344
818-360-2211 • info@valleyjcc.org