a minor, understand the risks and possibility of physical injury associated with basketball, and in consideration of accepting my child for the basketball team, all its member programs including the Shawnee Summer Basketball its facilities owners and sponsors, and associates, coaches, against any claim by or behalf of my child as a result of my child's participation in the Shawnee Summer Basketball activities.

Signature _______________________________________________

Address ________________________________________________

City __________________________________ State ____________ Zip _________________

-------------------------------------------------------------------------------------------------------------------------

As the parent or legal guardian of the above named child, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Dentistry. This care may be given under conditions to preserve life, limb, or overall well being of the dependant (Failure to sign indicates that you do not give consent).

NAME ____________________________________________________________(print)

Signature ____________________________________________________ Date _____________

Phone: ___________________________ Wk. Ph.________________________

Emergency contact name ________________________ Phone: _____________________

_______________________________________________________________________________