Keystone Youth Basketball Registration Form

2025/26 Keystone Youth Basketball Registration Form

Please note: EACH player must have their own registration form submitted.
2nd/3rd Grade Cost: $30
K/1st Grade Cost: $15
Payment Methods Accepted: Venmo (@keystoneathleticboosters), Cash or
Check to Keystone Athletic Boosters, 580 Opportunity Way, Lagrange, Ohio 44050
Be sure to include a note for Venmo and Checks: “KYB Registration – Player’s Name”

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Your registration form has been submitted.

Player’s First and Last Name

Player’s Grade

Boy or Girl

Player’s Birth Date (MM/DD/YYYY)

Home Address

City

State

Phone

Player’s T-Shirt Size

Are you interested in volunteering to coach?

Yes No

If Yes, enter your name and best number to reach you:

Emergency Contact

Emergency Contact Phone Number

EMERGENCY MEDICAL INFORMATION
PART I – TO GRANT CONSENT
In the event reasonable attempts to contact me at the above listed phone number, or contact of other parent/guardian at above listed phone number, have been unsuccessful, I hereby give consent for (1) the administration of any treatment deemed necessary by preferred Physician listed below, or preferred Dentist listed below, of, in the event the designated practitioner is not available, by another licensed physician or dentist: (2) The transfer of the child to preferred hospital listed below, or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical options of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

PART II – REFUSAL TO CONSENT
I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the Keystone Youth Basketball to take no action or to:

I do or do not grant consent(required)

Yes, I do grant consent No, I do not grant consent

Enter specific instructions if not granting consent:

FINAL SIGNATURES AND APPROVALS

By checking the box, you hereby give approval for the above named child to participate in any and all activities of the Keystone Youth Basketball program. You assume all risks and hazards incidental to such participation including transportation to and from activities, and do hereby waive, release, absolve, indemnify and agree to hold harmless Keystone Youth Basketball, the organizers, sponsors, supervisors, participants, field owners and persons transporting players to and from activities, from any claim arising out of an injury to a player, except to the extent and in the amount covered by liability insurance held by the local league.

Electronic Signature

Today’s Date (MM/DD/YYYY)

By checking this box, you agree the above electronic signature solidifies your approval and agreement on the details of this registration form.