Autumn Guide 2018

Registration Form Participant: _______________________________________________________ Male o Female o Age (if under 18): _____________________ Birth Date: __________________________________ Parent/Guardian (if under 18): ________________________________________________________ Email address (required): ____________________________________________________________ * Future transactions can be conducted online from anywhere, any time! No need to come to the office, email, mail or fax! Home Phone: _______________________ Cell Phone: ___________________________________ Address: __________________________________________________________________________ City/Town: ____________________________________________State: _________ Zip: __________ Emergency Contact: ______________________________________Phone:_____________________ Grade: ________School Attending: _____________________________________________________ Would you be interested in being a coach or assistant coach? Yes o No o Please select from the following: Registration Form Participant: ________________________________________________________________________ M Age (if under 18): __________________ Birth Date: __________________________________ Parent/Guard an (if under 18): Email address ( r quired ): __________________________________________________________ * Future transactions can be conducted online from anywhere, any time! No need to come to the offic Home Phone: ______________________________________ Cell Phone: _________________________ Address: ______________________________________________________________________________ City/Town: __________________________________________________________________ State: ____ Emergency Contact: ______ Phone: ________ Grade: _____________ School Attending: ___________________________________________________ Would you be interested in being a coach or assistant coach? Yes o No Please select from the following:

BOYS BASKETBALL (please note: we do NOT have sample sizes) Jersey size: Youth SM " MD " LG " Adult SM " MD " LG " XL " Shorts size: Youth SM " MD " LG " Adult SM " MD " LG " XL " GIRLS BASKETBALL (please note: we do NOT have sample sizes) Jersey size: Youth SM " MD " LG " Adult SM " MD " LG " XL " Shorts size: Youth SM " MD " LG " Adult SM " MD " LG " XL "

If you will be taking trips with us in our vehicles, you must provide the following information: (this does not apply to youth programs) If you will be aking trips with s in our vehicles, you must provide the following information: (this does not apply to youth programs) In the event over-the-counter medication is necessary, I give permission for the trip leader to admin- ister medication to myself as a participant or for my son, daughter or ward as a participant. Examples of medications used, but not limited to: (please select all medications you give permission to administer): Anti-diarrhea o  betadine o  iodine o  Neosporin o  Benadryl o  acetaminophen o sting-eze o  cold compress o What is your doctor’s name? __________________________________________________________ What is your doctor’s phone number? __________________________________________________ Where would you like to be picked up for trips? (Select one) o Montgomery County Government Center, 755 Roanoke St., Christiansburg, Very back parking lot o First & Main Shopping Center, 1490 S. Main St., Behind Anytime Fitness In the event over-the-counter medication is necessary, I give permission for the trip leader to administer as a participant or for my son, daughter or ward as a participant. Examples of medications used, but not l select all medications you give permission to administer): Anti-diarrhea " betadine " iodine " Neos orin " Benadryl " acetamin phen " sting-eze " cold What is your doctor’s name? _____________________________________________________________________________________ What is your doctor’s phone number? _________________________________________________________________________________ Where would you like to be picked up for trips? (Select one) " Montgomery County Government Center, 755 Roanoke St., Christiansburg, Very back parking lot " First & Main Shopping Center, 1490 S. Main St., Behind Anytime Fitness

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