REGISTRATION FORM Mississauga Wolverines Basketball Association Inc.Fax: 905-569-6929 www.mississaugawolverines.com 2014-2015 SKILLS DEVELOPMENT/HOUSE LEAGUE REGISTRATION FORM (One form per applicant)Athlete InfoName*FirstLastBirthdate* Gender*MaleFemaleDivision (age)*Minis (Ages 5-7) $300Atom (Ages 8-9) $325Major Atom (Ages 10-11) $340Bantam (Ages 12-13) $360Midget (Ages 14-17) $380Medical ConcernsSaturday SessionAll DivisionsMonday SessionAtomMajor AtomBantam Please check oneReturning WolverineNew WolverineParent / Guardian InfoName*FirstLastAddress*Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryEmail*PhoneMedical ConcernsIf Yes, please state: House league sessions start after Thanksgiving and run for 20 sessions with a break for the Christmas Holidays and New Year. The Mississauga Wolverines Basketball Association Inc. (MWBA). will do what it can to ensure the dates and times of the sessions are not changed, but participants acknowledge and agree that dates and times may change subject to notice, due to matters beyond the MWBA’s control. The registration fee provides the athlete one season with the Mississauga Wolverines, uniform and trophy. I hereby promise to obey all rules, regulations and code of conduct of Mississauga Wolverines Basketball Association Inc. (Wolverines). I am an amateur in good standing and will not play for any other team in this or any other league without written authorization from the Wolverines executive. The Wolverines will not be liable for any injuries received while playing or for loss of or damage to equipment. NO CLAIM – I hereby agree that I shall make no claim and bring no action, suit or proceeding for any and all damages, losses, liabilities or cost in any manner suffered or incurred as a result of my participating in the activities for which I have registered herein, and I hereby release the Wolverines and their administration, the City of Mississauga and the owner/occupier of the facility in which I participate from any and all damages, losses, liabilities, or costs in this regard. PHOTO RELEASE AND INDEMNITY – The Wolverines are authorized to take photos of my child or me at its programs for publicity and promotional purposes only. I hereby acknowledge and agree that the Wolverines may use and disclose the information of this form to enable the Wolverines to provide membership benefits to all Wolverine members. REFUND POLICY – Refunds must be requested no later than two weeks after the start of session. The refund will only be issued upon receipt of completed refund application form obtained from the Wolverines office. The amount of refund will be the session fee less a $50 administration charge. DECLARATION OF RESIDENCY – The player/parent acknowledges by his/her signature that he/she is a resident of Mississauga. If the player is not resident then he/she must fill out a non-residency form at registration.Parent / Guardian SignatureAthlete SignatureDate Signed Cost: Method of PaymentChequeCashCheque by MailNameThis field is for validation purposes and should be left unchanged.