2011-12 Seneca Falls Parks & Recreation Youth Basketball Program Registration Form Junior Division Girls And Boys Grades 5-6
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1RECEIPT #_______________
CA/CK AMT_______________
2011-12
SENECA FALLS PARKS & RECREATION
YOUTH BASKETBALL PROGRAM REGISTRATION FORM
JUNIOR DIVISION GIRLS AND BOYS GRADES 5-6
PLEASE PRINT!
PLAYERS NAME___________________________________________DOB_____/_____/_____ AGE________(Present)
ADDRESS____________________________________________MALE____FEMALE____GRADE_____(as of Sept. ’11)
PHONE#______________________EMERGENCY CONTACT PHONE#______________________________________
PARENT/GUARDIAN DATA:
NAME_________________________________________________SPOUSE___________________________________
ADDRESS______________________________________________ADDRESS_________________________________
PHONE#(DAY)___________________(EVE)_________________PHONE#(DAY)___________________(EVE)_______
EMPLOYER__________________________________________EMPLOYER___________________________________
FAMILY E-MAIL ADDRESS:_______________________________________________________
PLEASE CHECK HERE IF PARTICIPATING IN THE FINGER LAKES TRAVEL LEAGUE:
_____FL BOYS TRAVEL LEAGUE 5 & 6
______FL GIRLS TRAVEL LEAGUE 5 & 6
PARTICIPANT: SHIRT SIZE (CHECK ONE) ______10-12
_____14-16
_____ ADULT SM ______ ADULT MED
______ ADULT LG
_____ ADULT XL _____ OTHER
I REALIZE THE SUCCESS OF MY YOUNGSTER’S PARTICIPATION IS POSSIBLE ONLY THROUGH
VOLUNTEER PARENTAL SUPPORT. I WILL HELP AS FOLLOWS:
__________ HEAD COACH
__________ ASST. COACH
VOLUNTEER’S NAME __________________________________LEAGUE __________________________________
COACHES T-SHIRT SIZE: _______ SM _______ MED _______ LG _______ XLG _______ XXLG _______ OTHER
PARENT T-SHIRT SIZE (ONLY FOR FAMILY FASTBREAK):
______SM ______MED_______LG______XLG______XXLG______OTHER
LIABILITY WAIVER
I the undersigned, agree to let my child participate in the Seneca Falls Recreation Center & Parks Commission’s
BASKETBALL LEAGUE program mentioned above. I understand and agree that the SENECA FALLS RECREATION
CENTER & PARKS COMMISSION, its DIRECTORS, MANAGERS, COACHES and OTHER ORGANIZERS shall in no
way be held liable for any injury received at any game or practice, or in going to or from any game or practice. I
understand that it shall be my responsibility to transport my child to and from all games and practices.
BASKETBALL is a sport involving extensive running, contact and other physical exercise. I understand it is my
responsibility, through consultation with our family physician, to insure that my child is fit to participate in this program.
I do, hereby, assume all NORMAL risks and hazards incidental to the conduct of the above named program. I
further release, absolve, indemnify and hold blameless the SENECA FALLS RECREATION CENTER & PARKS
COMMISSION or any of the personnel appointed by that COMMISSION or the TOWN OF SENECA FALLS.
________________________________
________________________________
DATE
SIGNATURE OF PARENT/GUARDIAN
DELIVER OR MAIL COMPLETED FORM AND PAYMENT TO: SENECA FALLS REC & PARKS, 35 WATER ST., SENECA FALLS, NY 13148.
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