Winter Basketball Registration 2019 UPW Basketball League & Clinic Parent Release Form Child's Name* First Last Age*Grade*UPW Program that your child attends* Freedom Victory Promise Hope Harmony Amen UrbanPromise School none Child's Tshirt size* Child's Small Child's Medium Child's Large Adult Small Adult Medium Adult Large Will your student be ridding in UrbanPromise transportation? Yes No Pickup Location East Side - Ezion Mt Carmel, 800 N Walnut St, 19801 North Side - UrbanPromise Elementary School, 2401 Thatcher St, 19802 SouthBridge - Mt Joy UMC, 455 Townsend St, 19801 West Side - Haven Staff House, 1707 W 3rd St, 19805 Any Medical Concerns?**If your student has asthma, then your child is required to have their inhaler at every basketball related activity in order to participate**Parent Name* First Last Relationship*Parent Email Home PhoneCell PhoneWork PhoneEmergency Contact (other than parent)* First Last Phone*Please read carefully, and check that you agree:* I give permission for my child to participate in the activities sponsored by UrbanPromise and other cooperating organizations in the neighborhood. * I understand the risk involved in this program and that the staff will exercise all reasonable care for my child. I will not hold UrbanPromise Ministries, Inc., or other cooperating organizations, their staff or representatives, responsible for injuries which occur to my child. * In case of a medical emergency, I understand that an effort will be made to reach me. However, I do give permission for the staff of this program to authorize emergency medical care for my child. * I understand that Christian education is part of the UrbanPromise Basketball Program. * I understand that UrbanPromise and the cooperating organizations are not responsible for my child until and unless they arrive at the program site. If they need transportation, it will be once the child enters and exits the vehicle to go to and from the vehicle. * I give permission for my child’s name and photograph to be used in publications produced by UrbanPromise Ministries, Inc. * I agree to support my child and the staff of this program through accepting and enforcing the discipline structure that is used PhoneThis field is for validation purposes and should be left unchanged.