TEAM SANTA CRUZ FALL "TUNE UP" CLINIC

TSC Fall "Tune Up" Basketball Clinic October 13-14th, 2012 14th, held at- Santa Cruz High School Gym Registration Deadline: Wed., Oct. 10th For children grades 3rd-8th 3rd Boys and Girls welcome!

Childs Name: __________________________________ Date of Birth: ________________ Address: ____________________________________________________________________ City: __________________________________ Zip __________________________________ E-mail address: ________________________________________________________________ mail ________________________________________________________________ Age: __________Last school grade completed: _________________ Male/Female ________ Parent/Guardian(s) Name: _______________________________________________________ Home Phone: _________________Work Phone: _____________ Cell Phone: ____________ _____________ In case of emergency, contact ____________________________ Phone: _________________ Special concerns (allergies, medications, medical conditions, etc.) __________________________________________________________________ _______________________________________________________ ___________________________________________
I, the undersigned parent/guardian, do hereby grant permission for my son/daughter, named above, to permission attend Team Santa Cruz Fall "Tune-Up" Basketball Clinic, 2012. I will not hold the Basketball Coaching Staff , Team Santa Cruz, as well as its representatives, or the Santa Cruz High School gym and facility liable in the event of injury to my child. It is further understood that if an accident occurs the parents primary insurance will provide the necessary care. ry I further acknowledge and understand that my child will be responsible for his/her failure to abide by the rules and regulations of the clinic clinic. Signature of Parent or Guardian: ______________________________ _______________________________________ Date: ____________________

REGISTRATION INFORMATION $75 for 2 days, if pay by Oct. 5 ($85 if paid after) $40 for 1 day, if pay by Oct. 5 ($50 if paid after) Please make checks payable to Team Santa Cruz" Registration form MUST be mailed in with Medical Waiver Mail Registration form by Monday, October 8, 2012 to: Team Santa Cruz Attn. Ian Swift Cruz, 500 Chestnut St., Suite 100 Santa Cruz, CA 95062 For questions or additional forms: Ian Swift, Team Santa Cruz, at (831) 459-9992, ext. 108 (office), (831) 345 9992, 345-7584 (cell) or, ihswift08@gmail.com

Please note: We may take pictures during activities. Please indicate if you would prefer that your childs f picture not be used on any of Team Santa Cruzs promotional materials.

Medical Release and Indemnification Form

Childs Name Medical insurance carrier Policy number Doctor Dentist Medical conditions that we should be aware of Is your child currently taking any medications? If so, what are they? Phone Phone

Person to notify in case of emergency: 1. 2. Phone Phone

I hereby authorize the coaching staff of Team Santa Cruz to act for me according to their best judgment in any emergency requiring medical attention and hereby waive and release Team Santa Cruz or its members from any and all liability for any injuries or illness incurred while involved with team activities. I will be responsible for any medical or other charges in connection with my sons participation. I know of no mental or physical problem which may affect my sons safe participation in this program. I submit that my child is physically fit to participate in strenuous activities and I understand that basketball is an activity that places an enormous amount of physical strain on any athlete. I further agree to forever discharge any and all claims that I, we may have against Team Santa Cruz or AAU, its sustained as a result of my childs participation. Team Santa Cruz reserves the right to dismiss any participate without refund of fees for misconduct or anti-social behavior. My signature constitutes my understanding and acceptance of the above.

Parent or Guardians Signature Date