Summer Ball (Register) | Dinamite Volleyball

DINAMITE SUMMER BALL LEAGUE
2024 REGISTRATION FORM

This registration session will allow you to complete contact information, sign up for participation, and submit payment.

Please read through each page carefully to ensure that all information is provided accurately.

To complete registration through our secure site, please have your Visa, MasterCard, Discover, or ACH Bank Account information available.

PARTICIPANT'S INFORMATION (Required)

Participant's First name

Participant's Last name

Participant's Birthday

Participant's Address

Emergency and Medical Contact (Required)

In an emergency, when parents cannot be reached, please contact:

Primary Emergency Contact First Name:

Primary Emergency Contact Last Name:

Primary Emergency Contact Relationship to Player:

Primary Emergency Contact Cell Phone

Primary Emergency Contact Alternate Phone:

Insurance Information

If said participant is covered by any insurance company, please complete the following:

Medical Insurance Company:

Medical Insurance Policy Number:

Medical Insurance Group Number:

Medical Insurance Phone Number:

Physician Information

Physician's First Name:

Physician's Last Name:

Hospital of Choice

Physician’s Phone:

Medical History

If the answer to any of the following questions (below), is yes, please describe the problem and its implications for proper first aid treatment within the registration.

Please list any allergies we should be made aware of:

Please list any other medical conditions that we need to be aware of:

Please list any medications that are currently being taken:

PARENT/GUARDIAN INFORMATION (Required)

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Cell Phone

Parent/Guardian Email

PARENT/GUARDIAN 2 INFORMATION (if applicable)

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Email

Parent/Guardian 2 Cell Phone

I/We have read, understand and agree to comply with the Parent/Guardian Consent And Medical Release as outlined below:

The Participant being registered, has my permission to participate in training, competition, events, activities and travel sponsored by USA Volleyball or any of its Regional Volleyball Associations (RVAs). I approve of the leaders who will be in charge of this program. I recognize that the leaders are serving to the best of their ability. I certify that the participant has full medical insurance with the company listed above. I understand and agree that this document will be kept in the possession of authorized adult team personnel and that reasonable care will be used to keep this information confidential. I agree to allow the authorized adult team personnel to release this information in the event of a medical emergency to a third party medical provider. I also certify to the best of my knowledge that the participant named hereon is physically fit to engage in the activities described above.

I/We have read, understand the Emergency Medical /Dental Care Authorization as outlined below:

If, during the course of my daughter's/son's activities in volleyball, she/he should become ill or sustain an injury, I hereby authorize you to obtain emergency medical/dental care. I will assume financial responsibility for the bills incurred through my insurance company.

I do not authorize emergency medical/dental care for my daughter/son.

I/We have read, understand and agree to comply with the Waiver as outlined hereRelease, Waiver and Assumption of Risk

I/We have read, understand and agree to comply with the Waiver as outlined here

HEADS UP Concussion Waiver

Parent Guardian Signature

Thanks for registering. See you there!

DINAMITE SUMMER BALL LEAGUE 2024 REGISTRATION FORM