Lower Bucks Lightning

Club Registration

Please use the form below to register and send $250.00

Lower Bucks Basketball Group- P.O. Box 1142 - Langhorne PA. 19047    or pay securely on-line by clicking here 

Player Name
Birth Date
LBL Coach in 2009(if applicable)
Sex	Male Female
School
Grade (2009/10 School Year)
Street Address
Address (cont.)
City
State
County
Zip/Postal Code
Mother's Name
Father's Name
Cell Phone
Home Phone
Parent's E-mail (Club Use Only)
EmergencyContact
Emergency Phone
Dr.'s Name/Phone
Health Ins Co Name
Health Ins Co ID#

Participants Medical History & Permission Statement - Must be completed by Parent or Guardian

 

Has your child ever been treated by a Doctor for, or experienced, any of the following?  Please check “Yes” or “No”:

Head Injury: No   Yes	Concussion:  No   Yes	Dizzy Spells: No    Yes
Asthma:    No   Yes	Fainting: No   Yes	Anemia: No    Yes
Back Injury:  No   Yes	Diabetes:   No   Yes	Fatigue: No    Yes
Heart Problem: No   Yes

 

Is your child allergic to any drugs, serums, adhesive tapes or insects?

Drug Allergy No    Yes

Please explain:

Is your child allergic to any food or other substances?

Food Allergy No    Yes

 

 Please explain:

Has your child ever been told not to participate in sports because of a health problem?

Health Problem No    Yes

 

Please explain:

Does your child take medication regularly?

Medication No    Yes

 

Please list medications:

 

Has your child had any serious illness or operation in the past year?

Operation No    Yes

 

Please explain:

 

Is your child currently under a Doctor’s care?

Doctor Care No    Yes

 

Please explain:

Is there any medical condition that would limit your child’s participation in our program?

Medical Condition No    Yes

 

Please explain:

 

 

 

(Player’s Name) has my permission to participate in the Lower Bucks Lightning Basketball program.  I hereby assume all risks associated with the participation of my child in the Lower Bucks Basketball program and agree to hold harmless the Lower Bucks Lightning organization, its officers, coaches, and participants for any and all claims for injuries arising out of participation in this program.  I have completed and understand the details of this form and attest to its accuracy.  I certify that my child has primary health insurance with the above carrier.  I also give permission for my child to be examined and treated by a physician in case of emergency.

 

Signature (Parent / Guardian):   Date:  

 

Registration Fee (9/1/09 to 8/31/10):      $225.00 before 12/31/09        or        $250.00 after 12/31/09

 

Checks made out to: Lower Bucks Lightning Basketball

Mail to: Lower Bucks Basketball Group, P.O. Box 1142, Langhorne, PA  19047 or Register Online