Payment Information

Amount Paid $______

Date Paid ______

Cash ______Check #______

Miscellaneous______

SKILLS TESTDO NOT WRITE IN THIS AREA—VISION BASKETBALL STAFF ONLY

Years of basketball league experience: ______Height: _____Ft. _____In.

Shooting (30 Seconds) Total shots made outside line: ______Total shots made of 5 from line: ______

Lay-ups (30 Seconds) Total shots made left side: ______Right side: ______

Dribbling (30 Seconds) Total trips around cone: ______Previous year evaluation: ______

Vision Basketball APPLICATION

SHIRT SIZE (PLEASE CHECK ONE)

Please note! We will order the size indicated on the application. If the size is incorrect on the application, payment for replacing the shirt will be the responsibility of the player, parent or legal guardian. We will have sample shirts available at sign-ups and at the Sycamore Church of Christ building.

Youth Sizes Adult Sizes

LG = 14-16M = 10-12XLGLG

S = 6-8MS

PLAYER INFORMATION

For proper team placement please complete all of the requested information:

Age Date of Birth (MM/DD/YY) Grade in schoolHeightFt.InMale Female

Name

Address

City Zip Code

Phone # Cell Phone # Message Phone #

E-mail address

Church Affiliation

How many years experience do you (the player) have in organized basketball leagues?

PARENT/GUARDIAN INFORMATION

Father’s name Cell Phone Number

Mother’s name Cell Phone Number

Guardian’s name Cell Phone Number

E-mail address that is checked regularly

Name of step-parent living with you in your home

Page 2 of the application, the Liability Release Form must be completed prior to placement on a team.

This Instrument Prepared by:

Steven D. Qualls, Attorney at Law, 165 E. Spring Street, Cookeville, TN 38501

RELEASE FROM LIABILITY

I, , hereby release from any and all liability and hold harmless,Vision Basketball association and any of

its agents whether individually or collectively from any injury or death to my child,,either directly or

indirectly through his or her participation in Vision Basketball. I understand that Vision Basketball will primarily be played at the facilities of Collegeside, Jefferson Avenue churches of Christ and Algood Elementary School. However, I understand that this release from liability would include any transportation to and from anyfacilities associated with my child’s participation in Vision Basketball, including any practices, games or activities of any kind. I further understand that this release from liability extends to and includes Collegeside church of Christ, Willow Avenue church ofChrist, and any other churches affiliated with Vision Basketball.

Dated this day of , 2010.

Parent or Legal GuardianVision Basketball, Agent

CONSENT FOR MEDICAL TREATMENT

I, , parent of, a minor, dohereby authorize adult workers associated with

Vision Basketball association and its agents for the undersigned, to consent toany examination, x-ray, anesthetic, medical or

surgical diagnosis or treatment and hospital care which is rendered under supervisionof any physician or surgeon licensed

under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or medical center, whether such

diagnosis or treatment is rendered at the office of said physician, hospital, or other medical centerfor rendering of such services.

Dated this day of , 2010.

Parent or Legal GuardianVision Basketball, Agent

Player & Parent / Legal Guardian please read and sign the statement below.

I understand this is a Christian league, and I will not dispute with the referees, coaches, or Vision Board, and I will respect the decisions that are made during games and practices. It is understood that failure to comply

with this statement may result in dismissal from the league.

Player’s SignatureDate

Parent or Legal Guardian’s SignatureDate