Registration Form – Officials Coach / Executive / Ref Name(required) Role(required) NCCP# Address(required) City/Town(required) Postal Code(required) Home Phone Number Work Phone Number Cell Phone Number Email Address(required) Date of Birth yy/mm/dd(required) Gender(required) Male Female Emergency Contact(required) Emergency Contact Number(required) Media Release I hereby authorize any images or video footage taken of me, in whole or in part, individually or in conjunction with other images and video footage, to be displayed on the Southern Victoria Minor Basketball Association Website, Facebook and other official channels, and to be used for media purposes including promotional presentations and marketing campaigns. I also authorize the display and use of any media material created by me within the SV Minor Basketball Association. I waive rights to privacy and compensation, which I may have in connection with such use of my name and likeness, including rights to be written copy that may be created in connection with video production, editing and promotion therewith. I am over 19 years-of-age and I have read this waiver and am familiar with its content.(required) In lieu of a signature, please type your full name to confirm and agree with the above statement (required) Submit Share this:TwitterFacebookPinterestPocket