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Fall Youth Basketball
Boys & Girls Grades 3-8
Player Information:                             
Last Name:                    First Name:                                       M___ F___

Address:                       E-Mail Address:

Phone:                                          Current Grade:              D.O.B.

Mother’s Name:                          Father’s Name:

Work Phone:                                     Day/Work Phone:

Medical Problems/Allergies:               Doctors Name:

Person to Notify in Emergency (include telephone # if different from above)

Waiver and Consent to Medical Treatment

I, the undersigned parent/guardian of______________________________, request that he/she be allowed to participate in the activities provided by the Rutland Recreation Committee and in consideration thereof hereby agree that the Town of Rutland, through its Recreation Committee, its agents, servants, employees, coaches and volunteers, shall be held harmless and indemnified from and against any and all claims that may be brought as a result of my child’s participation in said activities.  In addition, should my child’s parent/guardian not be available to consent to medical treatment of ____________________________, that he/she may receive such medical treatment as deemed necessary by the staff, coaches, agents, servants, or employees of Rutland Recreation Committee.

Signature:_________________________________ Date___________

Fee:    Boys & Girls grades 3-5 $60 1 ½ per week
        Boy & Girls grades 6-8 $120 3 hours per week

Starting the week of Sept 9th   Total of 8 Weeks
  • Monday 6:00 to 7:30 3rd – 5th boys              7:30 to 9:00 6th – 8th boys
  • Wednesday 6:00 to 7:30 6th – 8th girls          7:30 to 9:00 6th – 8th boys
  • Thursday 6:00 to 7:30 3rd – 5th girls           7:30 to 9:00 6th – 8th girls
20 children maximum for level

Check # ___________    Cash ____________
                Contact us with any questions at 508-886-0048
                                                        visit our website:

Town of Rutland 250 Main Street, Rutland, MA 01543   Disclaimer
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