Cloverleaf HS Youth 
   Summer Basketball Clinic 
For Boys and Girls Grades 1-8 
Instruction By Cloverleaf BB Boys’ & Girls’ Staffs and Players 
Wednesday, June 28th @ Cloverleaf Elementary School 
Grades 1-5 from 3-5 p.m. and Grades 6-8 from 5-7 p.m. 
Please fill out and return registration form and waiver along with $20 clinic fee on the day of event! 
*Please make checks out to “Cloverleaf All Sport Boosters.”  
 
PLAYER NAME:___________________________GENDER: ____GRADE ( 2017-18): ____SHIRT SIZE (Indicate Youth or Adult): _____ STREET ADDRESS: _____________________________________________CITY: __________________ ZIP: ______________ SCHOOL:_____________________________PHONE: ______________________EMAIL: _____________________________  
PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR AGREEMENT AUTHORIZATION AND RELEASE OF LIABILITY: 
I, the parent/guardian of the registered child, authorize participation of my child in the Cloverleaf HS Basketball Clinic. This Release of Liability shall be as broadly construed as allowed by law to include all claims and rights that the child, that I as parent/guardian, may have. I am a legally responsible parent or guardian of my child. If any provision of this Release of Liability is deemed invalid, the remaining provisions shall remain in full force and effect. MEDICAL CONDITIONS I understand that participation in the Program may involve strenuous and prolonged physical activity. I agree that my child is healthy and able to participate in the Program activities. CONSENT TO MEDICAL TREATMENT In the event my child is injured or becomes ill in Program activities, I hereby authorize the Clinic staff, in my absence, to arrange for and consent on my behalf to emergency medical and dental care and treatment. I am responsi-ble for payment of any medical charges or expenses not covered by my insurance or the insurance applicable to my child (if any). My signature below indicates that all information provided in this form is true and accurate, and that I fully agree to all statements made on the form. 
Parent/Guardian Signature:_________________________________________________________ 
Printed Name:____________________________________________________Date:____________  
 
FOR ?’s: PLEASE CONTACT JACK BANKS AT  jbanks616@gmail.com or JOHN CARMIGIANO AT john.carmigiano@cloverleaflocal.org