Gilead Friends Church

Hoops for Him

2010 Registration
Child’s Name______________________________________________________________________________

Age ________ as of 3/5/10 DOB ____________________ Male or Female Height_______________

Father’s Name _____________________________ Mother’s Name _________________________________

Address____________________________________ if different __________________________________

__________________________________________ ____________________________________________

Phone:____________________________________ Phone: _________________________________

Marital Status: Single Married Separated Divorced email address:___________________________

Emergency Contact Name: ___________________________________ Phone __________________________

Do you or your child attend church? Yes or No

If so where?________________________________________

Would you like more information on Gilead Friends Church? Yes or No

Has your child played in Hoops for Him previous years? Yes or No How many years?_________

Would you be willing to coach? Yes or No Would you be willing to be an assistant coach? Yes or
No
Age group preferred to coach?_________________

Players shirt - Circle one: Shirt Size - Child Y-Sm Y-Med Y-Lg Y-XL Adult S M L XL

If you are interested in purchasing additional shirts to match your child’s for the games at a cost of $10 per shirt,
please indicate the sizes and quantities below. The shirts must be paid upon ordering.

Extra Shirt Size/ quantity: Child size YSm_____ Ymed____ YLg____ YXLg___
Ault Size S _____ M____ L____ XL____ 2XL____ 3XL____
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Hoops for Him use only: Method of Payment:

Dribble 1 2 3 4 5 _____cash amt ________scholarship

Shoot 1 2 3 4 5 _____check amt ________check #

Passing 1 2 3 4 5 _____amt paid for extra T-Shirts

Insurance Provider__________________________________

Parent or Guardian child has insurance under______________________________

AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT

I (We) ______________________________ and __________________________________

(father or legal guardian) (mother)

Are the parent(s)/legal guardian(s), with legal custody of ____________________________

(child’s name)

who is ________, and resides with us at ________________________________________

(age) (full address)

_________________________________________________________________________

Give our permission for a licensed doctor, physician, or emergency treatment center selected by the Hoops for
Him coach/representative to administer the necessary attention and aid IMMEDIATELY to our child should
he/she become injured or sick during Hoops for Him games or practices and to do so without having to wait
until we are contacted. We consent to any X-rays, examination, anesthetic, medical or surgical diagnosis,
treatment and hospital care deemed necessary.

We understand that Hoops for Him coach/representative will endeavor to reach us should the nature of the
injury or illness warrant it. However, we will not hold any of the Gilead Friends Church, Gilead Christian
School or the Hoops for Him coach/representative responsible if efforts to contact me (us) are unsuccessful.

I have read the rules and policies of the Hoops for Him program and as a parent promise to adhere to these
rules.

Hoops for Him, Gilead Friends Church & Gilead Christian School are not responsible for accidents or injuries
occurring before, during or after any Hoops for Him basketball games or practices.

_____________________________________________ __________________________
Parent Signature/ Legal Guardian Date

I give Gilead Friends Church permission to use pictures of my child for the benefit of the Hoops for Him
program.

______________________________________________________
Parent or Legal Guardian Signature