Basketball Registration Form - City Of Willowick

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WILLOWICK YOUTH BASKETBALL REGISTRATION
CHILD’S NAME_______________________________
___________
GRADE_______
DATE OF BIRTH
PLEASE CIRCLE ONE OF THE FOLLOWING DIVISIONS:
CO-ED:
BOYS
GRADES 1-2
: GRADES 5-6
BOYS
: GRADES 7-8
CO-ED
GIRLS
: GRADES 3-4
: GRADES 5-6
______________________
_______________ZIP_______
(_____)___________
ADDRESS
CITY
PHONE
FATHER’S NAME
MOTHER’S NAME
________________________
_____________________________
? YES___ NO___
HEIGHT_________
IS YOUR CHILD COVERED BY MEDICAL INSURANCE
:____________________
DESCRIBE ANY ALLERGIES OR SPECIAL MEDICAL CONSIDERATIONS
____________________________________________________________________________________
I GIVE CONSENT FOR EMERGENCY MEDICAL TREATMENT OF MY:
SON
DAUGHTER
(circle one)
YES ___________ NO______________ INITIALS_________________
PARENT/GUARDIAN SIGNATURE_________________________________________DATE______________
PLEASE READ AND SIGN WAIVERS ON BACK ALSO**
**
DID YOU PLAY LAST YEAR? YES _______ NO_______ Where? _________________________________
?
ON MIDDLE SCHOOL TEAM THIS YEAR
No _____Yes_____ School
_____________________________
CHILD’S SHIRT SIZE (CIRCLE ONE)
Youth - M
L
Adult - S
M
L
XL
REGISTRATION FEE
RES
NON-RES
SIGNUP DEADLINE
APPROX. START
Oct. 17
GRADES 1-2 CO-ED
$45
$55
Nov. 7
Oct. 17
GRADES 3-4 CO-ED
$50
$60
Nov. 7
Oct. 24
GRADES 5-6 BOYS
$50
$60
Nov. 16
Dec. 12
GRADES 5-6 GIRLS
$50
$60
Jan. 11
Jan. 16
GRADES 7-8 BOYS
$60
$70
Feb. 8
DATE______________
PAYMENT METHOD_____________
REC-ID ________ TOTAL PAID______________

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