2012 Registration Form

         Decatur Youth Basketball Program

                                            (Organized by Parks & Recreation)

For Boys and Girls in Grades K thru 5        

Decatur Residents and North Adams Community School Systems Only

Registration Begins: Sept. 18, 2012 Registration Ends: Oct. 12, 2012

Fee: $33.00

Meet on Sundays - Oct. 28, Nov. 4, 11 & 18, Dec. 2 & 9

Times: Boys K, 1st & 2 - 1:00-1:50 - Girls K thru 5th 2:00-2:50 and Boys 3,4,5 - 3:00-3:50

Deadline to Register – Friday, Oct. 12th  (office closes at 4 on Fridays)

*** Please drop off or mail forms (with payment) at the

        Parks & Rec. Office @ 231 E. Monroe Street or call 724- 2520 for more information!

DO NOT RETURN TO YOUR CHILD’S SCHOOL.

Player_______________________________Boy__Girl__Date of Birth_________

              First                                          Last

Address_________________________________Phone_____________________

Current Grade_________________School_______________________________

T-Shirt Size: Youth      M (10-12)     L (14-16)                             Adult              S     M     L

(PLEASE CIRCLE ONE)

Primary Head of Household                                                              Secondary Head of Household

Name:_______________________________                  Name:_________________________________

Address:_____________________________                  Address:_______________________________

Home Phone:_________________________                  Home Phone:___________________________

Work Phone:_________________________                  Work Phone:____________________________

Cell Phone:___________________________                   Cell Phone:______________________________

Volunteers needed to help coach and teach the fundamentals of basketball.

Volunteer's Name____________________________________ Preferred Phone#________________________

Age (if you are a young adult)__________________                    T-Shirt Size:____________________________

Volunteers - Are required to fill out a Coaches / Volunteer / Instructors Background check form.

Parental Authorization

I, parent, or guardian of the above named candidate for a position on the Instructional Youth Basketball League activities during current season. I assume all risk and hazards incidental to such participation including transportation to and from the activities; and do hereby waive, release, absolve, indemnity and agree to hold harmless the local league organization, league players, the organizers, sponsors, supervisors, participants and persons transporting the player to and from activities for any claim arising out of injury to player.

I also grant permission to managing personnel or other league officers or representatives; to authorize and obtain medical care from any licensed physician, hospital or medical clinic should the player become ill or injured while neither parent or guardian is available to certificate prior to the start of the season if requested.

I do hereby agree to play with any team to which I am assigned by league officials.

______________________  __________________________  _______________

Signature of Parent of Guardian                   Relationship                                              Date