City: _____________________________________ P.C. _________________
Phone: (h) (______)________________ (c) (______)___________________
Player’s Name:____________________________________________________ Age: ______ Birthday: _______________ Grade ______
Current Team(s): ___________________________________ Division: _________ Sibling (if applicable): ___________________________
Medical Conditions: No Yes (please clarify): _____________________________________________________________________
Allergies: No Yes (please clarify): __________________________________________________________________________
Medications: No Yes (please clarify): __________________________________________________________________________
Additional information you may want us to know: __________________________________________________________________________
-Parent/Guardian - Primary Contact Emergency Contact
Emergency Contact: ______________________________
Phone: (c) (______)______________________________
Parental/Guardian Informed Consent & Release of Liability of Mount Saint Vincent University
Office use only
First 3 letters
Method of Payment: Cash Cheque Debit Visa MC AMEX
Card # ___________________________________________________________ Exp Date: __________
OFFICE USE ONLY: Entered in Computer: o Yes Registered by: _______ Date: ______________________ Auth# ___________
I, ________________________________________________________ (please print) the parent/guardian of the participant understand,
appreciate and accept the inherent physical risks of these activities. As a condition of registration, the parent/guardian of the participant
agree to accept full responsibility for any personal property loss or damage and/or any personal injury sustained by the participant and on
behalf of the participant release Mount Saint Vincent University, its employees, agents or volunteers from any loss, damage or injury that may
be suffered by the participant in connection with participation in the activity.
Mount Saint Vincent University reserves the right to: assign the participant to a group most appropriate for their age or ability, and to request
any participant to withdraw if the participant is not behaving in an appropriate and reasonable manner.
I understand and agree to the above and hereby give my child permission to:
take part in the MSVU Basketball youth sport activities.
be photographed by MSVU staff and hereby understand that such photographs become the property of Mount
Saint Vincent University and may be used for the purpose of any other promotional purposes deemed necessary
and/or relevant to this program.
in the case of a health emergency, I give permission for my child to be taken to the IWK hospital.
Date: ___________________________ Signature: ______________________________________________________________________
2021 Boys Basketball Games - Grades 7-9
Fee: $150.00 Includes a Jersey
REMINDER: TO PARTICIPATE IN THIS ACTIVITY, A PARENT OR GUARDIAN MUST BE PRESENT AT DROP OFF
ON THE FIRST DAY TO COMPLETE THE REQUIRED “UNIVERSITY ACTIVITIES WAIVER”.
-MOUNT MYSTICS - SPORT REGISTRATION FORM
- -Phone: 902-457-6420 msvu.ca/camps firstname.lastname@example.org
MSVU Rosaria Centre, 131 Lumpkin Road, Halifax, NS B3M 2J6
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