:______. Home Phone: (____)______-. Phone: (____)______-______ Bus. Phone: (____)______-______. First. Last,. E-mail Add
WE’RE ON YOUR TEAM Youth Basketball
League
Divisions: Learn the fundamentals of basketball in a positive and fun environment! Players build self-confidence, discover their personal best, and make new friends! Grades: K-8 Season: January-March Fees: Facility Member $104, Program Member $135 *Program Membership: $75 Annual Fee (covers entire family)
Aaron Martinez •
[email protected] • 805.969.3288 x109
REGISTRATION OPEN OCTOBER 5!
Practices once a week with Saturday games: •K • 1st/2nd • 3rd/4th Practices once a week with Friday games: • 5th/6th • Jr. High
PROGRAM REGISTRATION FORM Please sign liability waiver on back Parent/Guardian name:______________________________________________Birthdate:_____/_____/_____Gender: M____F____ First
Last,
Middle
Participant’s name:_________________________________________________Birthdate:_____/_____/_____Gender: M____F____ First
Last,
Middle
Address:_______________________________________________City:___________________________________Zip:__________ Home Phone: (____)______-______________Cell Phone: (____)______-_____________ Bus. Phone: (____)______-____________ E-mail Address: ______________________________________________School Name: _______________________ Grade: ______ Emergency Contact: _____________________ Phone #: (____)______-___________Comments: ____________________________ __________________________________________________________________________________________________________________________________
All fees are subject to change. No refunds will be issued after the class has begun. Credits will be reviewed on a case by case basis. A $5 fee applies when switching to another class/program, unless change is required by the instructor.
PROGRAM INFORMATION
Choose
Shirt size (if applicable) YS YM YL AS AM AL
I am interested in being a: Coach Assistant Coach Team Parent
Official
(sizes run small)
Program Name: __________________________ M T W Th F Sat Times: ___________ Dates:________________ Cost: ________ Program Name: __________________________ M T W Th F Sat Times: ___________ Dates:________________ Cost: ________ Program Name: __________________________ M T W Th F Sat Times: ___________ Dates:________________ Cost: ________ Total: Method of payment: (circle one)
Cash
Check #: _______
AMEX
Discover
MasterCard
Visa
Receipt #_______ Staff Initials ______
Credit Card Account: ___________________________ Expiration Date: ________ Card Security # (3 or 4 digits)_______ Card Holder’s Name: ___________________________________ Signature: ___________________________________
Channel Islands YMCA Santa Barbara, Montecito, Ventura, Camarillo, Lompoc, Santa Ynez & Youth and Family Services Consent to Treatment, Photographic Release, Insurance Disclaimer Consent To Emergency Medical and Dental Treatment (Please check appropriate box below.) As the parent [ ], domestic partner defined by State of California[ ], or authorized representative or legal guardian [ ], I hereby give consent to Channel Islands YMCA, and its employees and volunteers to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D.), Osteopath (D.O.) or Dentist (D.D.S.) for my child, _____________________________. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child named above. Photographic and Video Release I hereby give Channel Islands YMCA, including its volunteers, employees and any other persons and entities acting with its permission, or upon its authority, the absolute right and permission to take, copyright, use, and publish any photographs or video of or concerning my child for the purpose of any YMCA advertising, education, promotion, or other purpose consistent with the YMCA mission. I agree that any such photograph or video is the exclusive property of the Channel Islands YMCA, and I hereby waive all rights thereto. I further waive any and all rights to inspect and/or approve any printed or electronic material that may be used in conjunction with the photographs or video, or to approve the use to which the photographs or video may be applied. Insurance Disclaimer Channel Islands YMCA does not carry health or accident insurance on its members or participants. All expenses incurred in the treatment of illness, injuries or accidents will be the responsibility of the participant and his/hers parents. List all allergies including reactions to medications: _____________________________________________________________ List any fears that your child has: _____________________________________________________________________________ I have read, understand and accept the above conditions. ______________________________________ (Print) November, 2013
_________________________________ (Sign)
_______________ Date
