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This entire form must be completely filled out, signed by parent/guardian with a check in the amount of $105.00. Checks should be payable to "CRBA". Due to limited gym access and increased demand, registration for certain age groups may unfortunately be limited. Last year, players in several age groups that signed up late were unable to play. Players will be registered and accepted by date of receipt of completed registration form and payment. Boys and girls interested in travel program must must also complete the additional supplemental form.. No earrings or jewelry. Please allow 4-8 weeks for refunds which are subject to CRBA refund policy. Absolutely no registration accepted after draft or team selection, 5th grade and above.

Player Name (Last, First):___________________________________________________Circle One: Male/Female

Brth Date:____/____/____ Played in program last year (Yes/No)   Grade:____________

Player lives with(Mother, Father, both, other):___________________ E-mail Address:________________

Height:(inches)___________ School:________________________Interested in Travel (Yes/No)________________

Children in grades 2, 3, & 4 only may request to be on a team with one friend_______________________
(Unfortunately, we can not guarantee placement on a team with friends)

(Optional) 2-8th Grade: A maximum of one week night when student is unavailable for practice_____________________
(one day only, if more than one day chosen, your request will not be honored)

Relevant Medical conditions (if applicable):__________________________________________________________

Street Address_______________________ City:___________________ Zip:__________ Phone:(215) ______________

Father's name:_______________________Mother's name:________________________________

Address and telephone numbers of parent(s) if different than player/child.
__________________________________ ___________________________________________
__________________________________ ___________________________________________

I/We, the parent(s) or guardian(s) of the above named child, hereby give my/our approval to participate in any and all league activities. I/We assume all risk and hazards incidental to such participation, including transportation to and from the activities; and I/We do hereby waive, release, absolve, indemnify and agree to hold harmless the Council Rock Basketball Association, its officers and board members, the Council Rock School District, Northampton Township, their agents, board members, and employees, the organizers, sponsors, coaches, referees, agents, coordinators, and persons transporting my/our child to and from activities; for any claim arising out of an injury to my/our child, whether the result of negligence or from any other cause. I/We understand that the insurance carried by this Association covers only the amount that is not paid by my/our insurance carrier. My child is a resident of the Council Rock School District and/or the townships therein.

Signature(Parent or Guardian)____________________________________________________Date________________