Player Participation Checklist

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Welcome towww.premierebasketball.comPlayer Participation ChecklistHANDOUTSEvents CalendarGuardian Release & Risk StatementGym LocationsHealth Report & Medical Auth.Coaching Staff RosterTeam Fees & Photo ReleaseTeam ExpectationsRecurring Payment Auth. FormContact & Conflict InfoDeactivation Request Form*These forms can also be downloaded at www.premierebasketball.comBEFORE TRYING OUT OR PARTICIPATING IN FIRST PRACTICEContact Info and Conflict Info Sheet (New/Non-Active Players)Guardian Release and Risk Statement (New/Non-Active Players)TURN IN TO COACH OR ADMIN. AT OR BEFORE 2ND PRACTICEHealth Report and Medical Authorization (New/Non-Active Players)Team Fees and Photo Release (New/Non-Active Players)Recurring Payment Authorization Form (New/Non-Active Players)Grade Verification (Class Schedule or Copy of School ID) (New/Non-Active Players)Copy of Insurance Card (New/Non-Active Players)Copy of Birth Certificate (New/Non-Active Players)No team will be scheduled for any games until ALL players have submittedALL of the necessary paperwork. We appreciate your cooperation on this!Our Practice and Game Schedule Is Online at: www.premierebasketball.com

KCP Teams Schedule of Events CalendarWinter 2015-16www.premierebasketball.com*Teams will only be allowed to participate in games once ALL players have submitted ALL required paperworkDATEEVENTLOCATION10/30 – 11/1KCP/MAYB Halloween Hoopfest Tournament (3rd-12th)Shawnee Mission, KS11/1 – 12/13KCP Winter I League (Sundays Only)Metro Kansas City11/13 – 11/15KCP/MAYB Turkey Trot Tournament (3rd-8th)Johnson County, KS11/20 – 11/22KCP Bears Tomorrow Tournament (3rd-8th)Independence, MO12/11 – 12/13KCP/MAYB Snowball Shootout (3rd-8th)Johnson County, KS1/8 – 1/10KCP/MAYB Tournament (3rd-8th)Johnson County, KS1/10 – 2/21KCP Winter II League (Sundays Only)Metro Kansas City1/15 – 1/17KCP/MAYB Tournament (3rd-8th)Johnson County, KS2/5 – 2/7KCP/MAYB Tournament (3rd-8th)Johnson County, KS2/12 – 2/14KCP/MAYB Tournament (3rd-8th)Johnson County, KS2/26 – 2/28KCP/MAYB Tournament (3rd-8th)Johnson County, KSNote: The participation of our teams in tournaments is dependent upon the level / number of teams registered

Practice & Game Gym LocationsShawnee Mission School District (KCP South Practice)Belinder Elementary7230 BelinderShawnee Mission, KS 66208Brookridge Elementary School9920 LowellShawnee Mission, KS 66212Broadmoor Technical Center6701 W. 83rd St.Shawnee Mission, KS 66204Brookwood Elementary School3411 W. 103rd StreetShawnee Mission, KS 66206Comanche Elementary School8200 GrantShawnee Mission, KS 66212Corinth Elementary School8301 Mission Rd.Shawnee Mission, KS 66206Highlands Elementary School6200 RoeShawnee Mission, KS 66205Hocker Grove Middle School10400 Johnson DriveShawnee Mission, KS 66203Horizon High School5900 LamarShawnee Mission, KS 66202Indian Creek Technology Center4401 W. 103rd St.Shawnee Mission, KS 66207Indian Hills Middle School6400 Mission Rd.Shawnee Mission, KS 66208Indian Woods Middle School9700 WoodsonShawnee Mission, KS 66207McAuliffe Elementary School15600 W. 83rd St.Shawnee Mission, KS 66219Pawnee Elementary School9501 W. 91st St.Shawnee Mission, KS 66212Prairie Elementary School6642 Mission Rd.Shawnee Mission, KS 66208Santa Fe Trail Elementary School7100 LamarShawnee Mission, KS 66204Shawnee Mission East High School7500 Mission Rd.Shawnee Mission, KS 66208Shawnee Mission North High School7401 Johnson DriveShawnee Mission, KS 66202Shawnee Mission Northwest High School12701 W. 67th StShawnee Mission, KS 66216Shawnee Mission South High School5800 W. 107th St.Shawnee Mission, KS 66207Shawnee Mission West High School8800 W. 85th St.Shawnee Mission, KS 66212Sunflower Elementary School8955 Loiret BlvdShawnee Mission, KS 66219Trailridge Middle School7500 Quivira Rd.Shawnee Mission, KS 66216Trailwood Elementary School5101 W. 95th St.Shawnee Mission, KS 66207Westridge Middle School9300 Nieman Rd.Shawnee Mission, KS 66214Our practice/game schedule is online at: www.premierebasketball.com

Practice & Game Gym LocationsPark Hill School District (KCP North Practice)Chinn Elementary7100 N Chatham RdKansas City, MO 64151English Landing Elementary6500 NW Klamm DrKansas City, MO 64151Graden Elementary8804 NW 45 HwyParkville, MO 64152Hawthorn Elementary8200 N CharitonKansas City, MO 64152Line Creek Elementary5801 NW WaukomisKansas City, MO 64151Prairie Point Elementary8101 NW Belvidere PkwyKansas City, MO 64152Renner Elementary7401 NW Barry RdKansas City, MO 64152Southeast Elementary5704 NW NorthwoodKansas City, MO 64151Tiffany Ridge Elementary5301 NW Old Tiffany Springs RdKansas City, MO 64154Union Chapel Elementary7100 NW Hampton RdKansas City, MO 64152Plaza Middle School6501 NW72nd StKansas City, MO 64151Congress Middle School8150 N Congress AveKansas City, MO 64153Lakeview Middle School6720 NW 64th StKansas City, MO 64151Park Hill High School7701 NW Barry RdKansas City, MO 64153Park Hill South High School4500 River Park DriveRiverside MO 64150Independence School District (Games)Bingham Middle School1716 S Speck RdIndependence, MO 64057Clifford H. Nowlin Middle School2800 S HardyIndependence, MO 64052James Bridger Middle School18200 E M78 HwyIndependence, MO 64057Pioneer Ridge Middle School1656 S Speck RdIndependence, MO 64057Truman High School3301 S Noland RdIndependence, MO 64055Van Horn High School1109 S Arlington AveIndependence, MO 64053William Chrisman1223 N Nolan RdIndependence, MO 64050Our practice/game schedule is online at: www.premierebasketball.com

KCP SOUTH (SMSD)Coaching Staff2015 Winter Iwww.premierebasketball.comProgram DirectorEmailPhoneTJ Taylorkansascitypremiere@gmail.com(269) 615-0068Grade/TeamCoachEmailPhone3rd/4th BoysBubba Powellmarceljpowell@yahoo.com(913) 526-93753rd/4th BoysJoel Gerdesjoel gerdes@yahoo.com(913) 305-77165th/6th BoysTJ Taylorkansascitypremiere@gmail.com(269) 615-00687th BoysEric Berryericjberry1991@gmail.com(314) 255-46597th BoysNick Potthoffhuskerz1274@gmail.com(913) 515-84808th BoysTheron Sanderstheron.beau.sanders@gmail.com(913) 522-2092KCP NORTH (NORTHLAND)Program DirectorEmailPhoneTJ Taylorkansascitypremiere@gmail.com(269) 615-0068Grade/TeamCoachEmailPhone3rd/4th GirlsKristen Daviscoachdavis@earthlink.net(913) 634-45224th/5th GirlsJohn DooleRene Martinezjdoolep@aol.comrjm1martinez@gmail.com(913) 707-4828(913) 284-28645th/6th BoysTJ Taylorkansascitypremiere@gmail.com(269) 615-0068

www.premierebasketball.comKC Premiere Team ExpectationsIn order to build a stronger program and teams we have decided to implement new expectations. If youdo not feel that you or your son can meet these expectations, please contact us to discuss your options.COMMITMENT LEVELKC Premiere is seeking players with the highest possible level of commitment. For this reason, players who play othersports competitively and / or do not play basketball year round are discouraged from participating. Please disclose anyand all potential conflicts. We will not accommodate players who pan to participate on more than one basketball team.ATTENDANCE POLICY1. Any player who is late or absent from multiple practices, games, or other team activity (meeting), to theextent that it causes disruption to their Premiere team, will be asked to find another organization to play for.2. Players are required to be at practices on time and be at game locations one hour early to properly prepare.3. Any team that cannot maintain an 80% practice attendance rate will not be eligible to participate in games.PLAYER DEVELOPMENTPlayers who are serious about making it to the next level make the necessary sacrifices to improve their skills on adaily basis. Since we do not practice or play every day of the week, it is expected that all players devote at least FIVEadditional hours per week to basketball. Drills in the driveway, passing with parents, ball handling in the basement,and conditioning are a few suggestions. Coaches will be happy to provide additional ideas that are age appropriate.ACADEMICS1. Be the best STUDENT athlete you can be. Academics must be the top priority.2. Homework needs to be completed before coming to practice.3. You will not have the same energy level or the same concentration level after practice.TIME MANAGEMENT Each player should evaluate the number of hours they spend each day watching TV, playing on the internet,talking on the telephone, texting friends, playing video games, playing with devices, social networking, etc.If each player spent half of that time working on their homework and half that time on their basketball skills,players would more than double their chances of earning a college scholarship. Strong habits start early in life.SUBMISSION FEES Recurring payment plan is strongly encouraged for convenienceFees must be submitted on or before the first day of the month.Please submit to your coach or at the front table at any game site.If you have special financial circumstances, please let us know.If you are in need of scholarship assistance, please let us know.We rely solely on player fees to operate the program as promised.COMMUNICATIONParents of 3rd - 8th grade players are required to be at a brief team meeting at the end of every practice and everygame to discuss plans for the next team activity. This is the best way to make sure that everyone is on same page.FLEXIBILITY AND RESPONSIBILITY FOR BEHAVIORKC Premiere is typically the organization that is hosting the events we participate in. Without these leagues andtournaments, we would not be able to offer the opportunity for youth to play on a team operated by KC Premiere.This fact that you are representing KC Premiere Basketball comes with the added responsibility of:(1) Being flexible and available to play any extra games, even on short notice, as deemed necessary(2) A willingness to help set up or clean up the gyms if your team is playing the first or last game of the day(3) Setting the example for other teams to follow as it relates to sportsmanship, player, fans and coach behavior.KC Premiere fans are there to cheer for our team and not make any negative remarks to or about our opponents,their fans or coaches. We must take the higher road, bite our tongue and avoid setting a bad example at all costs.(4) Concerns about officiating should be directed immediately to the Program Director and only Program Director.Do not criticize the officials during a game, as this never ends well for the team, and does not yield desired result.

www.premierebasketball.comPlayer Contact Info / Conflict InfoPlayer Name:Grade:Player Cell:School Name:Parent #1 Name:Work Phone:Cell:Email:Parent #2 Name: Cell:Work Phone:Email:Home Phone:Player Lives With?:Home Address:City State ZipEmergency Contact Name:Relationship: Cell:Other sports played:Days / times of practices / games for other outside sports:Other extracurricular activities:Days / times of potential conflicts with other activities:I will be Out of Town Dates:Please communicate any and all conflicts with the coach of your team in writing

www.premierebasketball.comLiability Release & Risk StatementGuardian Release of Liability for Minor Child’s ParticipationIn consideration of (name of player), my/our child of minor age, being allowedto participate in any way in the Kansas City Premiere program, related events, and activities, the undersignedacknowledges, appreciates, and agrees that:1. The risk of injury from the activities involved in this program is significant, including thepotential for permanent paralysis and death, and while particular rules, equipment, andpersonal discipline may reduce this risk, the risk of serious injury to my/our child does exist;and,2. I knowingly and freely assume all such risks, both known and unknown, even if arising fromthe negligence of the releasees or others, and assumer full responsibility for my/our child’sparticipation; and3. I willingly agree to instruct my/our child to comply with the stated and customary terms andconditions for participation. If I observe any unusual significant concern in my/our child’sreadiness for participation and/or in the program itself, I will remove my child fromparticipation and bring such attention to the Program Director immediately; and,4. I, for myself and on behalf of my child, heirs, assigns, personal representatives and next of kin,hereby release, indemnify, and hold harmless the Kansas City Premiere, its coaching staff,officers, officials, agents, and/or employees, other participants, sponsoring agencies, individualsponsors, advertisers, and if applicable, owners and lessors of premises used to conduct theprogram/events (“Releasees”), with respect to any and all illness, injury, disability, death, orloss or damage to person or property incident to my/our child’s participation in this program,whether caused by the negligence of the releasees or otherwise, to the fullest extent permittedby law.I/we have read this release of liability, assumption of risk, and indemnity agreement. I/we fully understand itsterms and understand that I/we have given up substantial rights by signing it, and sign it freely and voluntarilywithout inducement.Signature of Parent/GuardianPrinted Name of Parent/GuardianDate SignedSignature of Parent/GuardianPrinted Name of Parent/GuardianDate SignedUnderstanding of Risk Statement for Minor ParticipantI wish to participate in the Kansas City Premiere Boys Basketball Program, related events and activities. In doingso, I understand and agree to the following statements:1. I understand that the activities involved in this program may cause serious illness or injury includingparalysis or even death; and,2. My parent(s)/guardian(s) is/are allowing me to participate in this program; and,3. My parent(s)/guardian(s) and I believe that I am physically and mentally able to participate fully in thisprogram. If I learn of or sense a change in my health or physical condition, I will stop participating andinform the coaching staff immediately; and,4. I will follow all known rules for participation. If I notice anything unsafe, I will stop participatingimmediately and inform the coaching staff; and,5. I am willing to accept all risks of being hurt, both known and unknown, and will take full responsibility formy behavior.I have read and understand this statement of risk. I agree with each of the terms above.Signature of Minor ParticipantPrinted name of Minor ParticipantDate Signed

www.premierebasketball.comHealth ReportDate:CONFIDENTIAL:Athlete’s Name:Home Address:Father’s Name:Mother’s Name:Grade:City:Work #:Work #:Birthdate:State:Home #:Home #:LOCAL EMERGENCY NUMBERS (To be called if Parent/Guardian cannot be reached)Name:Relationship:Phone:Primary Physician:Phone:Dentist:Phone:Is the athlete under physician’s care at this time? YES NOIf so, explain:Does athlete have allergies? YES NO If yes, please circle type: FOODINHALANTSASTHMADoes athlete take any medication for above allergies? YES NO Name of medication:Does athlete have a physical handicap? YES NO If yes, is itCONGENITALorACQUIREDPlease explain:Zip:HAY FEVERDoesYESYESYESYESYESYESathlete have a history of any of the following:NO Diabetes If yes, initial diagnosis (date)Under control? YES NO Medication?NO Hypoglycemia (low blood sugar)NO Sickle Cell AnemiaNO Throat Infections (chronic or strep)NO Convulsive disorders (seizures) Circle GRAND MAL PETIT MAL OTHER Medication?NO Fever convulsions - Date of last episodeDoesYESYESYESYESYESYESathlete have a history of any of the following:NO HyperventilationYESNO Fainting (explain)NO Head injuries or major accidents of any kind? ExplainNO Heart, cardiovascular disease or high blood pressure? ExplainNO HyperactivityYESNO Emotional problemsNO Vision – Glasses - Circle FULL TIME or PART-TIME Contact lenses Circle FULL TIME or PART-TIMENOEye surgery? ExplainLast tetanus immunizationHealth concerns not mentioned; include hospitalization or operation:In case of emergency, at which hospital do you want your child treated?I hereby authorize the physician in charge of (athlete’s name) to administer anytreatment or to administer such anesthetics, perform such operations as may be deemed necessary or advisable inthe diagnosis and treatment of this patient. I accept the treatment deemed necessary by the physician treating theemergency; if time allows I prefer that (physician’s name) treat my child.Date:Parent signature:Medical AuthorizationI/we hereby authorize the coaching staff of the Kansas City Premiere Boys Basketball Program to act according totheir best judgment in any situation requiring medical attention, whether an emergency or not, until such time asI/we can be contacted to make decisions regarding the treatment of (player name) .Signature of Parent/GuardianPrinted name of Parent/GuardianDate SignedSignature of Parent/GuardianPrinted name of Parent/GuardianDate Signed

www.premierebasketball.comPlayer Uniform Fees and Monthly DonationsPremiere Basketball is a state and federal non-profit organization under section 501(c)(3)The team budget is typically either upside down or barely above board at the end of each fiscal year.Fees are based on the expense involved in operating the teams for the season, and divided equallyeach month. Although some months may have more team events than others, fees are not prorated.Grade (Season)Uniform Fee*Monthly Fee (Recurring) Monthly Fee (Cash/Check)3rd-6th (KCP North) 75 50 703rd-9th (Fall / Winter) 75 100 120rdth3 -9 (Spring Summer) 125 100 12010th-12th (Fall / Winter) 75 100 12010th-12th (Spring Summer) 125 150 170*The replacement cost for each item is: Shooting Shirt 25, Shorts 30, Jersey 45, Backpack 40Monthly family donations are as follows: 50 (participation), 25 (coaching fee) and 25 (admin. fee)There will be a service charge of 20 / month for any payments that are not set up as recurring payments.Monthly Donation Options (please indicate which method of payment you intend to use):Recurring Payments (Please complete Recurring Payment Authorization Form)Other method (cash, money order, credit card or check include a 20 service fee)3rd-9th teams that travel, players are required to pay an additional 25 travel fee each month they travel.Typically youth teams would only travel during the months of May through August, and not in fall / winter.Uniform fees and family donations are non-refundable, but team may offer to “buy back” uniforms.No one will be turned away due to an inability to pay, however there is a limited amount of scholarshipassistance available for each team. In order to apply for a scholarship, please request an application.Scholarships will be granted only to individuals who have completed the application process each session.Parent SignatureDatePhoto and Information Release (For all Players)I,, a minor, give my permission to Premiere Basketball, Inc that they mayrelease and/or post my personal image(s) (photos) and /or biographical information including: parent/guardiannames, home address, e-mail address, academic and athletic related information and statistics (but notpersonal, home or cell phone telephone numbers unless duly authorized) on the KC Premiere Basketball website (www.premierebasketball.com) and/or any printed material designed for either program participant’spersonal promotion to coaches and colleges and/or for KC Premiere Basketball endorsement opportunities.By signing this agreement regarding Premiere Basketball, Inc. or KC Premiere Basketball’s distribution ofimages and/or information about said player/program participant, I hereby agree to hold harmless and excludeKC Premiere Basketball or Premiere Basketball, Inc. of any and all claims resulting from the unlawful and/orunauthorized use of said images and/or information by other known and/or unidentified individuals or parties.Signature of Player/ParticipantDate SignedSignature of Parent/GuardianDate Signed

www.premierebasketball.comRecurring Payment Authorization FormPremiere BasketballPO Box 14420Parkville, MO 64152Schedule your payments to be automatically charged to your credit/debit card.Here’s How Recurring Payments Work:You authorize regularly scheduled charges to your Visa, MasterCard, Discover Card or American Express.You will be charged each billing period for the total amount due for that period.This authorization will remain in effect until you cancel via email, at least 5 days prior to next billing date.Any changes / cancellations of this arrangement should be emailed to kansascitypremiere@gmail.comPlease complete the information below:I authorize Premiere Basketball, Inc. to charge my credit card(full name)indicated below each month for payment of my child’s monthly family donation.Player NameGradeI understand that this charge will be made between the 1st and 5th day of the month and that no priornotification will be provided.Billing AddressPhone#City, State, ZipEmailAmount To Be Debited Each MonthAccount Type:VisaMasterCardDiscoverAmerican ExpressCardholder NameAccount NumberExpiration DateCVV (3 digit number on back of Visa/MC)SIGNATUREDATEI authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlinedabove. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the nextbusiness day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business inwriting of any changes in my account information or termination of this authorization at least 5 days prior to the next billing date. Icertify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit cardcompany provided the transactions correspond to the terms and type of payment indicated on this authorization form.

www.premierebasketball.comPlayer Deactivation Request FormForm must be submitted by mail to the below address, or submitted via email to TJ Taylor,kansascitypremiere@gmail.com. This written form of documentation is required for a playerto become deactivated and monthly fees to no longer apply. Once received, confirmation fromKCP administration will be communicated, notifying of receipt and deactivation.Premiere BasketballPO Box 14420Parkville, MO 64152Deactivation of Monthly Fees:Monthly fees will still apply for the current month in session. Once this form is completed, submitted andconfirmed by KCP administration, your monthly fees will deactivate immediately for the following monthand thereafter. There is no prorating of fees.Example: If your child/ren wish to be deactivated for July, this form must be completed, submitted, andconfirmed with KCP administration by June 30th in order to avoid the July monthly fees.Reactivation:If your child/ren would like to be reactivated, please contact TJ Taylor, kansascitypremiere@gmail.comNo players are eligible for reactivation unless confirmed with KCP administration. Players not activated areNOT allowed to participate in any practices and/or games.Please complete the information below:I authorize Premiere Basketball, Inc. to deactivate the following(full name)player, effective as of .(date)Player NameGradeReason for DeactivationI understand this player deactivation request is not complete until submitted to Premiere Basketball viamail (PO Box 14420, Parkville, MO 64152) or emailed to TJ Taylor, kansascitypremiere@gmail.com ANDconfirmed with communication by KCP administration, notifying receipt of deactivation.I understand monthly fees still apply for the current month and will not be deactivated until this form iscompleted, submitted and confirmed by KCP administration. Once deactivation is confirmed by KCPadministration, I understand monthly fees will deactivate immediately for the following month andthereafter. I understand there is no prorating of fees.I understand players may not be reactivated without contacting and receiving confirmation from KCPadministration. I understand without reactivation, players are NOT allowed to participate in anypractices and/or games.SIGNATUREDATE

Shawnee Mission, KS 66219 Pawnee Elementary School 9501 W. 91st St. Shawnee Mission, KS 66212 Prairie Elementary School 6642 Mission Rd. Shawnee Mission, KS 66208 Santa Fe Trail Elementary School 7100 Lamar Shawnee Mission, KS 66204 Shawnee Mission East High School 7500 Mission Rd. Shawnee Mission, KS 66208 Shawnee Mission North High School

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