St. Mark Basketball League
2009 – 2010 Season
Permission Form

MY CHILD HAS MY PERMISSION TO PARTICIPATE IN THE ST. MARK LUTHERAN CHURCH BASKETBALL YOUTH PROGRAM. I UNDERSTAND THAT I WILL BE NOTIFIED AS SOON AS POSSIBLE IN AN EMERGENCY. HOWEVER, IN THE EVENT OF AN ACCIDENC, I WILL NOT HOLD ST. MARK LUTHERAN CHURCH OR THE ADULT SUPERVISORS RESPONSIBLE. I AUTHORIZE THE CALLING OF A DOCTOR TO ATTEND OR THE PROVIDING OF OTHER NECESSARY MEDICAL SERVICES AT MY EXPENSE.

SIGNATURE: [PARENT/LEGAL GUARDIAN] ___________________________

NAME OF CHILD: _______________________________________________

ADDRESS: ____________________________________________________

CITY:_______________ ZIPCODE:__________ PHONE: ______________

AGE: _______________ GRADE: ___________ SCHOOL: _____________

NAME OF PARENT OR LEGAL GUARDIAN: ____________________________

ADDRESS & PHONE [IF DIFFERENT FROM ABOVE]

NAME, ADDRESS & PHONE # OF AN ALTERNATIVE PERSON IN CASE THE PARENT/GUARDIAN CANNOT BE REACHED IN AN EMERGENCY.

REGISTRATION FEE: ST. MARK MEMBER:$65 UNIFORM:$20   SIZE: ______

PLEASE MAKE CHECK PAYABLE TO: ST. MARK BOOSTER CLUB