Town of Charlotte
2004 Youth Basketball Registration Form
Registration Deadline: November 19,
2004
Name_______________________________________
Grade ______ M / F
Parent (guardian)
Name: _________________________ Phone: ___________
Parent E-mail address
____________________
Special
needs/medical conditions (if
applicable):__________________________
____________________________________________________________
Coach ____ Assistant Coach ____ Team Helper ____ Tournament ____ Name: ______________ e-mail: ______________ Practice/Game
Schedule 1st graders: Monday 6:00 pm 2nd graders: M/W 6:00
pm. 3-4 girls:
M/W 6:00 pm, Sat. am. 3-4 boys:
T/H 6:00 pm, Sat. am. 5-6 girls:
W/H 6:00 pm, Sat. am. 5-6 boys:
T/W 6:00 pm, Sat. am.
Volunteers Needed!
T-Shirt Size
Youth: M
L
Adult: S
M
L
Checks payable to
Town of Charlotte.
Return form and
fee to Town Hall drop box or mail to
P.O. Box 119 Charlotte, VT
05445.
WAIVER: I
give permission for my child to participate in the Town of Charlotte intramural
sports program. Prior to my child’s
participation in the program, I will inform the instructor of any health
problems or restrictions that will affect my child’s participation in the
program. I understand that the
possibility of injury is inherent in recreational activities. In consideration of your acceptance of my
child’s entry, I hereby, for myself, my child, and our heirs, executors and
administrators, waive and release any and all rights, claims and damages we may
have against the Town of Charlotte, its representatives and volunteers,
successors and assigns, for any and all injuries suffered by either of us at
any activity sponsored by this group.
In the event of an emergency, I give permission for the above-mentioned
child to receive medical treatment and to be transported by ambulance if
necessary. I have provided the Town of
Charlotte with medical information pertinent to my child’s participation in any
recreation program and by this release authorize the dissemination of that
information for any medical care and treatment. I am aware that the Town of Charlotte may take photographs of
participants at programs, activities and special events. I am aware that the pictures may appear in
promotional materials, including brochures.
I hereby certify that I am a person having legal responsibility for the
child and that I am duly authorized to execute this release form.
Parent or Guardian
Signature: _____________________________________________Date: __________