**Registration fee is $25.  Following registration (below), you will be directed to an option to pay online via PayPal (+small service fee).  You may also pay in person (cash/check only).

Player Information

Returning Player?
Gender:
Current Grade:
Player’s Name: *
Date of Birth (mm-dd-yyyy):
Phone Number:
Email: *
Facebook Name:
Twitter handle:
Mailing Address:

School Team

Which school does the player attend?
School Coach’s Name:
School Team:
Position(s):
Please list any and all other activities the player will participate in that may conflict with AAU basketball:

Parent Information

Mother Name:
Mother Phone:
Father Name:
Father Phone:
Emergency Contact Name: *
Emergency Contact Phone: *

Parent/Guardian Involvement

Would you like to participate?
If so, Describe how you’d like to help (i.e. team parent, help w/fundraiser):

Medical

Any medical, physical, or allergy conditions?
Physician Name:
Medical Condition Details:
Physician Phone:

Insurance Information

Medical Insurance Company:
ID Number:
Group Number:

Parent / Guardian Agreement

1. I, being the parent of the above-named player, hereby give my approval for his/her participation in the Mid-Penn Motion (MPM) an AAU basketball club. I assume all risks and hazards incidental to such participation including transportation to and from activities; and I do hereby waive, release, absolve, indemnify and agree to hold harmless Mid-Penn Motion, its officers, coaches, agents, partners being successors, any sponsors, organizers, owners of facilities used, supervisors, and participants for any and all claims arising out of injury to my child. 2. I hereby authorize Mid-Penn Motion officials, coaches, assistant coaches, team parents, or any responsible persons delegated to any of the above to take my child to the nearest hospital or any other accredited medical establishment for emergency treatment in case of injury during practice and/or games if the parents are not available. I will assume any and all financial responsibility. I have read and fully understand the above conditions: 3. It is a goal of the MPM organization to gain exposure and publicity for its players. As a result each team page on the MPM website will list the full names of the players and display a team photo. If a parent does not want a child’s last name and photo to appear on the website, it is his/her responsibility to inform the team coach. I have read the “Parent / Guardian Agreement”, and I agree to these conditions. Please enter the text in the graphic below: