On Line Registration Form

Please fill out this form, print and mail to:
Premier Athletics - Nebraska
P.O. Box 561
Elkhorn, NE 68022

CHOOSE PROGRAM (*Required Information)

Athlete's First and Last Name* Age*    Grade*

Address*

City* State* State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP*

Emergency Contact*

Emergency Phone (include area code)*

PAYMENT OPTIONS       Mail Payment        Bring Payment to Event

WAIVER OF LIABILITY
I authorize Premier Athletics of Nebraska to act as my agents in the event of a medical emergency. I acknowledge that the participation in athletic events involves the risk of physical injury, and as such, I hereby hold harmless and release Premier Athletics of Nebraska, its agents and employees from any demand, action or cause of claim arising out of our participation in any Premier Athletics event.
I agree