TUKWILA REIGN

                                           AAU GIRLS' BASKETBALL

                                         REGISTRATION FORM 2004

NAME:                                                        DOB:                                Age as of 1/1/01:

ADDRESS:                                                  Height:                              Grade:

CITY, STATE:                                                                                        ZIP:

Home PHONE:                                            Emergency PHONE:

Parent(s) Name:                                         Emergency Contact:

Father or Guardian Work PHONE:

Mother or Guardian Work PHONE:

School Attending:

Are you currently covered by Health and Accident Insurance? Yes:     No:

T‑SHIRT SIZE:  S   M   L   XL                             SHORTS SIZE:  S  M  L  XL  

                                                                        PARENTAL or GUARDIAN CONSENT

       I, the undersigned, as the parent or legal guardian of the child listed on this application, hereby assume full responsibility for all risk of injury or loss which may result from my child's participation in the Tukwila Reign season, practices, scrimmages and games. I understand that I am required to maintain and carry accident medical insurance coverage for the child listed on this application. In consideration of your acceptance of this entry, 1, intending to be legally bound, do hereby, for myself, the athletes, heirs, executors, and administrators, waive, release and forever discharge all rights and claims for damages which may have or which may hereafter accrue to the athletes against the Amateur Athletic Union of the United States, the National AAU Girls' Basketball Committee, the Tukwila Reign, the local host and facility owners or any other support group of organizations, their respective officers, agents, representatives, succors, and/or assigns for any and all damages which may be sustained and suffered by the athletes in connection with their association with or entry in the Tukwila Reign  program or which may arise out of traveling to or participation in, and returning from said season, practices, scrimmages and games, at all host  facilities.    

         I, or we the parent(s) or guardian of the athlete, grant to the Directors, Coaches or assigned chaperones of The Tukwila Reign to act as guardian/spokesperson in granting permission for emergency treatment/hospitalization (including anesthesia) if necessary for my/our daughter while in route to or from or at the sites of a Tukwila Reign program. I understand that should a health emergency arise, I will be notified, but that if I cannot be reached by telephone, such medical treatment as deemed necessary by competent medical personnel is authorized.

         Insurance: AAU membership provides excess medical insurance for any member athlete participation in an AAU‑sanctioned practice or event. If the athlete has other medical coverage, theirs will be applied first, followed by AAU insurance. If the athlete has no other coverage, the AAU policy becomes primary, subject to terms and conditions of the policy. There is a deductible fee.

Date:                     Parent(s) or Guardian Signature:                                                            /

EMERGENCY MEDICAL HISTORY (possession of coaches at all practices and games} 

Player's Name:                                                       Date of Last Tetanus Shot:

 Family Physician:                                                   Physician's PHONE:

 Insurance Co:                                                        Policy Number:

Frequent chest pains or palpitations?                                                          NO ‑ YES  Explain on reverse of form

Recent problems of fatigue?                                                                        NO ‑ YES  Explain on reverse of form

Is she allergic to any drugs, serums, adhesive tapes or insects?              NO ‑ YES  Explain on reverse of form

Has she ever been told not to participate in sports due to health               NO ‑ YES  Explain on reverse of form

problem?

Does she take medication regularly?                                                           NO ‑ YES  What &Why on reverse

Has she had any serious illness or operations in the past year?               NO ‑ YES  Explain on reverse of form

Is she presently under a doctor's care?                                                      NO ‑ YES Explain on reverse of form

 QUESTIONS: Please contact Wayne Severson, 246-9803; Jonathan Smith, 246-7845; Ron Phelps, 244-8819.

                                             Mail Registration Form to Tukwila Reign, c/o Wayne, 14225 42 "d Ave S. #222,

                                                                                            Tukwila, WA 98168