3D"Waynedale

Kindergarten = thru=20 5^th Grade &nbs= p; =20 Saturday Morning Games (9:15am or=20 10:30am)

February 18 =96 = March=20 24

Waynedale Baptist Church

633 Lower=20 Huntington Road

Registration=20 Sign-up at Church=20 Family Life Center on Saturday, January 21 = 10am-12noon

or earlier at Church Office = Monday-Thursday=20 10am-4pm. Call 747-5400 for details.

------------ Cut = and=20 return registration below to Church office on or before January 28th=20 ----------------

Player's = Name:___________________________ Age:______ Gender: M/F Birth=20 Date:____/____/____

Address:_________________________________________ =20 Zip:________ &nbs= p; =20 Phone:____________

Shirt Size: YS (6-8) =20 YM (10-12) =20 YL (14-16) =20 Adult Small =20 Adult Medium =20 Adult Large

Parent/Guardian = Name:=20 ___________________________________________________________________=

Alternate Phone = Number:=20 ___________________

Player Emergency=20 Information

Allergies:_________________________________ &nbs= p; =20 Medical Problems:_____________________

Medications:______________________________

Insurance = Name:___________________________ &nbs= p; =20 Policy Number:________________________

Primary Insured = Name:______________________

I=20 (we) hereby grant permission to seek medical treatment in the event I = cannot be=20 contacted. ________(Initial)

I=20 (we) do hereby release, absolve, indemnify, and otherwise hold blameless = Waynedale Baptist Church, the organizers, sponsors, directors, and the = officials=20 appointed by them, of any damages, demands or actions whatsoever, which = may=20 arise or grow out of his/her participation in the Waynedale Baptist = Church=20 Basketball League.

Parent/Guardian = Signature:=20 _________________________________________ = Date:=20 _____/_____/_____

Registrations = will not be=20 accepted after Saturday, January 28.

Please call = Church office=20 for questions at 747-5400.

Please make = checks payable=20 to Waynedale=20 Baptist Church