REGISTRATION FOR INDIVIDUALS & TEAMS
POINT BREEZE YOUTH DEVELOPMENT & BASKETBALL LEAGUE
Child's Name
Date of Birth
School Name
Grade
Address
City
Zip
State
Home Phone
Father's Name
Work Phone
Father's Email:
Cell Phone
Mother's Name
Work Phone
Mother's Email:
Cell Phone
List any medical conditions/concerns player has
I recognize many risk are associated with strenuous physical exertion in a Youth Basketball Program which may result in
serious injury or death. I certify to the best of my knowledge, my child's physical condition is satisfactory to participate in
physically demanding activities. I hereby release, discharge and/or otherwise indemnify Point Breeze Basketball League
affiliated organizations, sponsors, their employees and owners of facilities used for the program, against any claim by or on
behalf of the registrant as a result of the registrants participation in the program. As the parent or legal guardian of the above
named player, I hereby consent for emergency medical care prescribed by a duly licensed Doctor of Medicine. This care
may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent.
Today's Date
Online Individual Registration
Online Team Registration
DO YOU HAVE A TEAM? COME PLAY AGAINST US
School/Orgraniztion Name:
Address:
City, State & Zip:
Team Name:
Age of Players:
Coach/Captain Name:
Cell #:
Phone #:
Email Address:
Ages 14 & under -  $5 per person non refundable registration fee
Ages 15 & up - $10 per person non refundable registration fee