2007 / 2008 Charlton Youth Basketball
Program
Parents
Names: Mother: _________________________ Home Phone #:________________
Father:
_________________________ Cell Phone #:________________
E-mail:
______________________
Address:___________________________________________ Zip Code:___________
I, the parent/guardian of the registrant/s, a minor, give my permission for him / her to participate in the Charlton Youth Basketball Program, and further agree that I and the registrant/s will abide by the rules of the Charlton Youth Basketball Program. Recognizing the possibility of physical injury associated with basketball and in consideration for the Charlton Youth Basketball Program accepting the registrant/s for its basketball programs and activities, I hereby release, discharge and/or otherwise indemnify the Charlton Youth Basketball Program, its sponsors, volunteers, and associated personnel, as well as the owners of the basketball facilities used for the basketball program, against any claim by or on behalf of the registrant/s as a result of the registrant’s participation in the basketball program and/or being transported to or from the same, which transportation I hereby authorize. Registrant/s is in good health and able to participate in physical activity.
As parent or legal guardian of the below-named player/s, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependent.
Parent / Guardian Signature___________________________________________ Date______________
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Player Name Sex Grade Player Name Sex Grade
#1________________ ____
____ #3________________ ____ _____
#2________________ ____
____
#4________________ ____ _____
Primary
Physician:____________________________ Phone #:_______________
Fees:
Grades 1-4: #30.00 / Grades 5-12: $40.00 /
Check
#_______ Check Amount: $_______ Must receive payment with Registration form.
TEAM SPONSOR
Discount: Sponsor a team or find us a sponsor and get $25.00 off!!
Limit of one $25.00 discount
per
Because of the need to put
teams together for grades 5-12 we will not accept registrations after try-out
night, i.e. try-outs for 5th & 6th boys is October 9.
No registrations for 5th & 6th boys after that date.
** For those high school boys
& girls making their high school team, and are prohibited by the school coach
to participate in out of school programs, we will offer a $20 refund for each
affected player.
I would like to volunteer
for (check choice): Head Coach___ Asst. Coach___ Referee___
Other___
Note: Coaches are selected
by league directors and approved by Charlton Youth Basketball Board of
Directors.
ASK
FOR CORI PERMISSION
FORM - THIS MUST BE FILLED OUT & BROUGHT TO ONE OF THE CHARLTON OR