City of Winooski Youth Basketball Program

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City of Winooski Youth Basketball Program For Grades K-5 December 13th - February 14th At Winooski School Gym And Cafeteria Saturdays from 9:30AM - 11:00AM Grades K-5 Child’s Name:_______________________________________

Age:____________

Address:______________________________________________________________ Date of Birth:_____/______/_______

Grade:______________ Gender: M F

Are there any dates you won’t be able to make it?:_____________________________ Known Allergies/Medical Conditions:________________________________________ _____________________________________________________________________ Please write the name and claim number of your medical insurance: Insurance Company:_________________________ Claim Number:________________ Primary Language(s) Spoken At Home: ______________________________________ Basketball Experience:___________________________________________________ Parent/Guardian: Parent Filling Out Form: __________________________________________________ Phone:________________________E-Mail:________________________________ Additional Parent or Guardian:_____________________________________________ Phone:________________________E-Mail:________________________________ Emergency Contacts If Parent Not Available: Name:______________________________ Relationship To Child: ________________ Phone:________________________ E-Mail:__________________________________ Name:______________________________ Relationship To Child: ________________ Phone:________________________E-Mail:__________________________________

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PLEASE INITIAL NEXT TO EACH ITEM By initialing below, I hereby give my consent to the following: ______ General Liability Waiver: I hereby, on behalf of myself, my child, my heirs, executors or administrators, waive my right to any and all claims my child or I may have against the City of Winooski or any other person/entity related to this program. I understand that all activities have hazards, and I accept the risks posed by my child’s participation in the City of Winooski Youth Basketball Program. ______ Emergency Medical Care: I grant permission, in the case of an injury or medical emergency, for City of Winooski Youth Basketball Program staff to administer first aid or seek medical treatment for my child. I understand that staff will attempt to reach me (and/or other guardians or emergency contacts listed on my child’s enrollment form) in the case of an emergency, but I authorize them to undertake any actions they determine necessary in the interests of the health and safety of my child if they are unable to reach me or another emergency contact. In the event that emergency medical treatment is deemed necessary, I agree to be responsible for any and all expenses associated with treatment services. ______ Photography Release: I grant permission for photographs or videos to be taken of my child in the course of his/her participation in the City of Winooski Youth Basketball Program. I understand that these images will be used at the City’s discretion and may be published in various materials or media.

Parent Signature:____________________________________ Date:_____________ Please return this form with a $15.00 registration fee Cash or check made out to City of Winooski. Return to J.F.K. Office. Scholarships are available. Questions? Contact [email protected] or call 802-655-6410 Tracy LaFond at [email protected] or call 802-999-2041.