Address:

Phone:

E-Mail:

Date of Birth:

School:

School Coach:

Current Grade:
5th Grade
6th Grade

Player Experience:

By hitting "Send" I acknowledge my son/daughter is physically fit to participate in strenuous athletic activity and I waive Rome Select Basketball of any and all responsibility resulting in Injury or Illness. I hereby authorize the directors / coaches of Rome Select basketball to act for me according to their best judgment in any emergency requiring medical attention. I understand that I am solely responsible for the payment of any such medical expenses and must provide this organization with proof of medical and accident insurance before playing in any tournaments.

Are You Interested In Helping Out Being A:
Team Parent, Assistant Coach, or Head Coach? If So Which?

There are many activities for children and their families throughout the year with Rome Select Basketball. In many cases, there will be photography at these events. Rome Select Basketball will publish the photos from time to time for use on our website, as well as in addition to various print materials. We ask that parents of minor children to give permission for Rome Select to use their children's photos. Initial.

Name Of Parent/Guardian:

Parent/Guardian Phone:

Parent/Guardian Email:

Name Of Insurance Company:

Policy #: