Youth Recreation Basketball League
2009-2010 Registration Form
Circle One: 7/8 Boys 7/8 Girls 5/6 Boys 5/6 Girls
3/4 Girls 3/4 Boys 1/2 Co-Ed Kinderball
I give the Town of New Durham permission to include my child in photos taken throughout the season and to display them at their discretion on the Town of New Durham website. INITIAL:
First Name__________________________Last Name___________________________
Age________ Grade_________ Sex_________
Address_______________________________________New Durham, NH 03855
Phone Number __________________________
Parent/Legal Guardian Information:
Mother’s Name___________________________________________________________
Hm Phone________________Work_________________Cell______________________
I would like to Volunteer as a: (Circle)
Coach (Discount) / Asst Coach (Discount) / Team Parent / Ref (Pd) / Scoreboard Operator
Father’s Name____________________________________________________________
Hm Phone________________Work_________________Cell______________________
I would like to Volunteer as a: (Circle)
Coach (Discount) / Asst Coach (Discount) / Team Parent / Ref (Pd) / Scoreboard Operator
Family Email address (for last-minute updates)_______________________________
My business wants to sponsor my child’s team: N / Y, Business Name: _________________
Phone#_________________ Contact:_______________________
Emergency Contacts:
Name____________________________Phone_______________Relationship_________
Name____________________________Phone_______________Relationship_________
Doctor’s Name____________________Phone____________________
Preferred Hospital____________________________
Medical Conditions we should be aware of: ____________________________________
________________________________________________________________________
SEASON FEES: The 2009-10 season registration fee for grades K-2 is $25.00 per participant.
The 2009-10 season registration fee for grades 3-8 is $40.00 per participant.
Please Make Checks Payable to the Town of New Durham
Waiver and Release of Liabilities
Participation in the basketball league may involve risk of injury, but not limited to sprains, bruises, torn muscles, broken bones, eye and head injuries. The program also involves traveling to other towns to play games. As a parent or guardian I attest and verify that I have full knowledge of the risks involved and that my child is physically fit to participate in the basketball league. I hereby for myself, my heirs, executors, and administrators waive and release all rights and claims against the town of New Durham, its officers, agents, employees, and volunteers, except in the case of their sole negligence, from all losses, injury, damages, fees, and other expenses arising out or in connection with participation in the basketball league. In addition, I give my permission for my child to be
treated by qualified medical personnel in the event that I can not be reached at the phone numbers provided. Date ________________________
PrintName___________________________________Signature______________________
(Parent or Legal Guardian ONLY)
Office Use: Amt. Pd. $_________ Date ______________ Cash/Check # ___________
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