THE BROWNSON HOUSE SPORT'SPROGRAMS FORM
(Circle One)Boy's Basketball Girls Basketball Football Flag Football
(Age Group)___________ __________ ________ __________
Name: _______________________________________________ Date: _____________________
Address: _____________________________________________ Home Phone: _______________.
____________________________________________ Work Phone: ________________
E-Mail Address: _______________________________________
Team : ______________________________________________
Birth Date ____________________________________________ Grade: __________________
Father _______________________________________________ Do you have hospitalization coverage?
NameEmployed byYes _____ No ______
Mother _______________________________________________
My son/daughter has my permission to participate in Youth Leagues & other activities during the time his or her group are scheduled. I will not hold any adult advisor or anyone responsible for any injury or illness that might occur during practice sessions, games or transit. I agree to indemnity & save harmless the Brownson House Inc. from any & all liability or damages they may be required to pay for my child. I certify my son/daughter has been examined & is physically fit to participate.
______________________________________________________________________
