55 Gordon Street, Suite 2A ~ Whitby, ON ~ L1N 0J2
Telephone: (416) 477-8075 Email: info@basketball.on.ca Website: www.basketball.on.ca

ONTARIO BASKETBALL MEMBERSHIP APPLICATION

________________________ ____________ _______________________________ _______

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FIRST NAME MIDDLE INITIAL LAST NAME

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GENDER DATE OF BIRTH (MM/DD/YY)

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ADDRESS

(_____)__________________

HOME PHONE

CITY

POSTAL CODE

________ (_____)__________________

WORK EXT. FAX

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EMAIL ADDRESS

(_____)__________________

WORK PHONE

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CLUB TEAM NAME (eg. OBA Hoops # 1)

MEMBERSHIP CATEGORY

􏰀 Active Member 􏰀 Rep Team Player 􏰀 House League Player 􏰀 Adult House League Player 􏰀 OBA Event Fee: $45.00 Fee: $20.00 Fee: $2.50 Fee: $5.00 Fee: Varies Please refer to back of this page for description of each membership category.

CATEGORY OF PLAY

􏰀 U11 Atom
􏰀 U14 Major Bantam 􏰀 U17 Juvenile

REGION

􏰀 York-Durham 􏰀 Toronto
􏰀 Hamilton-Niagara 􏰀 Kitchener-Waterloo

􏰀 U10 Novice
􏰀 U13 Bantam
􏰀 U16 Major Midget

􏰀 Capital
􏰀 Peel-Halton

NCCP – Learn to Train
NCCP – Train to Train
NCCP – Train to Compete
NCCP # _____________________

IF COACHING PLEASE PROVIDE GENDER OF TEAM COACHING

􏰀 Male 􏰀 Female

I hereby agree, in return for becoming a member of the Ontario Basketball Association (OBA):

• 􏰁  TO RELEASE THE OBA, event organization bodies, sanctioning bodies and OBA sponsors and their respective directors, officers, employees, agents, volunteers,

  contractors, representatives, successors or assigns (collectively the “Releasees”) from any liability for any loss, damage, injury or expense (collectively “Loss”) that I may

  suffer as a result of my participation in and transportation to or from any OBA program, due to any cause, including negligence or breach of contract;

• 􏰁  TO WAIVE ANY CLAIM that I have or may have against any or all of the Releasees regarding any matter, including without limitation, any claim arising out of any OBA

  program;

• 􏰁  TO INDEMNIFY THE RELEASEES from any and all claims, actions or Loss resulting in any way from my participation or participation of the child named below in any OBA

  program;

• 􏰁  THIS DOCUMENT SHALL bind my heirs, executors, administrators, assigns and representatives and will have effect throughout my membership in the OBA and, to the

  extent reasonably necessary to give it effect, thereafter;

• 􏰁  THAT I am (or the child named below is) physically fit to participate in any OBA programs; I am a legal guardian or custodial parent of the child named below.

• 􏰁  THAT the OBA is authorized to take photos of the child named below or me at its programs for publicity and promotional purposes only.

• 􏰁  I hereby acknowledge and agree that OBA may use and disclose the information on this form to enable OBA to provide membership benefits to all OBA members.

  I HAVE READ AND UNDERSTAND THIS AGREEMENT. By submitting this application, I acknowledge having read, understood and agree to the above Waiver, Release and Indemnity and further agree to conduct myself in accordance with the ‘Guidelines for Behavior’ at OBA Sanctioned Events, as set out on the reverse of this form.

• ______  Date Completed _________________

• ______  Date Completed _________________

• ______  Date Completed _________________

􏰀 U12 Major Atom 􏰀 U15 Midget
􏰀 U19 Junior

􏰀 North 􏰀 West

IF COACHING PLEASE PROVIDE CURRENT NCCP STATUS

WAIVER, RELEASE & INDEMNITY-RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS, PHOTO RELEASE & INDEMNITY

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Signature

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Signature of Parent or Legal Guardian – If Participant is under 18 years of age

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Date

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PRINT name of Child Participating and Relationship (i.e. Jane Doe – Daughter)