I certify that __________________________ has permission to attend the winter program and further give consent for medical treatment for above listed child in the event that a need for immediate medical attention arises. If such need arises. I agree to the release of any records necessary for treatment, referral, billing and insurance purposes, and give permission for a camp nurse/EMT to inform the necessary parties of my child’s medical conditions, including, but not limited to, food or other allergies, asthma, seizures, or medication for attending to my child’s medical needs. I understand that some activities are inherently risky and take full responsibility for above listed child’s participation in any of the fall programs, and indemnify, release and discharge West Branch Area School District / Warrior Basketball and it’s directors, officers, employees and agents from liability and all costs arising from about listed child’s participation in basketball activities. I herby authorize Geisinger of Philipsburg, Clearfield Hospital, Mount Nittany or E.M.T’s to provide care that includes routine diagnostic procedures. _________________________________________________________________________________________________________ SignaturePrint Date I understand that the consent and authorization herein granted does not include major surgical procedures and are valid only during the fall program. Please list below any physical conditions that the clinician should be aware of Pre-Existing Circulatory/Pulmonary Conditons: ______________________________________________________________ Diabetes: Yes / No Inhalers: Yes / No Do you have current Health Insurance: Yes / No Allergies or Allergic Reactions: ____________________________________________________________________ ____________________________________________________________________ Medications Being Used: ____________________________________________________________________ ____________________________________________________________________ In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me/us. However, in the event of an emergency, and if I/we can not be reached, I give my consent for physicians and staff of Geisinger of Philipsburg, Clearfield Hospital Emergency/Outpatient Department, Mount Nittany or any E.M.T to perform any necessary emergency treatment. I/We agree to the release of any records necessary for treatment, referral, billing, or insurance purposes to the appropriate medical care provider. Emergency Contact: ______________________________________________________________________________________________ Name / Relationship Address Phone (Home) (Cell) ______________________________________________________________________________________________ Name / Relationship Address Phone (Home) (Cell) ______________________________________________________________________________________________ Name / Relationship Address Phone (Home) (Cell) ______________________________________________________________________________________________ Family Physician Address Phone I/We, the undersigned, individual and as parent(s)/Guardian of _______________________, a minor, ask that he be admitted to participate in the winter program at the West Branch Area School District and any tournaments. In consideration of such admission, I/We do hereby agree to release, discharge, and hold harmless the Warrior Basketball program/West Branch Area School District, any coaches or volunteers, it’s officers, agents, and employees of and from all causes, liabilities, damages, claims or demands whatsoever on account of any injury or accident involving the above said minor arising out of the minor’s attendance at the winter program or in the course of competition and / or activities held in connection with the winter program. ___________________________________________________________________________________________ Mother/Guardians’ Signature Date Father/Guardians’ Signature Date

Registration Form ELEMENTARY WARRIOR BASKETBALL West Branch School Gym $30.00 registration fee required with completed form. Please make checks payable to: Nik Bisko FORM MUST BE COMPLETED BY PARENT OR GUARDIAN. PLEASE FILL IN ALL SECTIONS _________________________________________________________________________________________ Last NameFirst Name MI _________________________________________________________________________________________ Birth DateAgeGrade _________________________________________________________________________________________ Home Address (No. and Street or Box No.) _________________________________________________________________________________________ CityStateZip _________________________________________________________________________________________ Home Phone Address _________________________________________________________________________________________ Mother’s/Guardian’s NameHome Phone No.Cell Phone No. _________________________________________________________________________________________ Father’s/Guardian’s NameHome Phone No.Cell Phone No. In case we need to cancel practice early, and you can’t be reached who else may we call to pick up your child. ________________________________________________________________________________________ Name / RelationshipHome Phone No. Cell Phone No. ________________________________________________________________________________________ Name / RelationshipHome Phone No. Cell Phone No. ________________________________________________________________________________________ Name / RelationshipHome Phone No. Cell Phone No. Registration Fee Paid ___________________Cash___________________Check Shirt Size __________________________ Jersey Number ______________________

West Branch Elementary Boys Basketball (Grades 2-3) Coaches: Chad Koleno and Mark Norris Contacts: Chad Koleno: Home number: Mark Norris: All that is needed for practice is sneakers. If you have your clearances through West Branch and want to help please contact Chad Koleno. If you want to help and do not have your clearances please see Kasi Woodring in the administration wing for assistance. We will NOT have practice if school leaves out early for bad weather. Games: Thursday, January 15 th and January 23 rd. We will play during the halftime of Boys JV and Varsity games. Please be there by 6:00. Players get in free Parents will need to pay. We are going try and play at least one other team from another school this year(TBA). All kids need is a little help, a little hope and somebody who believes in them. -- Magic Johnson, great motivational basketball quotes "Just play. Have fun. Enjoy the game.“ Michael Jordan quote