Fall / Winter League 2017 – Player Registration Form

Fill up the field boxes with the information needed. Field with (*) is required.
Your browser's javascript must be enabled.

Activity Information

(mm/dd/yyyy)
(mm/dd/yyyy)
$
Add to Total Fee after deadline
(mm/dd/yyyy) Registration is based on actual submission date
(+)number denotes days passed deadline

Player Information

(mm/dd/yyyy)
(Based on Start Date)
Extra line for address

Division and Fee Table

Note: Minimum of eight (8) games including play-offs. Fee in USD.
Choose a Division
$

Parent or Guardian Information

First and Last Names
ex. Father, Mother, Aunt or Others
Home or Mobile
Home or Mobile
All communication will be sent to this address

Medical and Health Information

To call in case of emergency
ex. Father, Mother, Uncle or Others
Home or Mobile
Home or Mobile
Name of family physician
Name of covering Insurance company

Permission and Release Declaration

I hereby give permission for the above Player to participate in the FYBA Basketball League activity and agree that he/she will abide by all the rules and regulations of the facility/area and/or the Filipino-American Youth Basketball Association and its designated officers and agents.
 
In case of accident or illness, please contact the name of above listed Contact Person at his/her Contact Number.
 
In the event of an accident or injury, I, as parent or guardian of the above child, hereby waive liability for the Fil-Am Youth Basketball Association and their officers and will hold them harmless. I understand that there is no medical insurance being provided by the Filipino-American Youth Basketball Association.
 
PHOTO RELEASE: I give my consent for pictures taken of my child involved in Filipino-American Youth Basketball Association (FYBA) programs to be used for future FYBA promotions or display.

Payment Information

Debit or Credit Card payment is not available at the moment.
$
$
$
$
Note: Please prepare your Credit Card now. After you click the 'Submit' button, the subsequent page needs some details of your card information. Before clicking the 'Submit' button, please review carefully your entries above and make necessary changes if needed.
Note: Write your check payable to FYBA Inc. with the amount in the 'Total Amount Due'. Enclose this check with a copy of the email message you will receive and send them to 'FYBA Inc. 7386 Shady Palm Drive, Springfield, VA 22153'. Before clicking the 'Submit' button, please review carefully your entries above and make necessary changes if needed.