Registration will take place on Saturday, 11/2/13 in the basement of the town hall.
RUTLAND RECREATION YOUTH BASKETBALL
For Boys & Girls Grades K-11
T-Shirt Size: YS YM YL AS AM
Player Name: _________________________________________ M ___ F___
E-Mail Address: _____________________________________________________
Phone: _____________________ Current Grade: _________ D.O.B. ___________
Parent Name (s) ________________________________________________________
Medical Problems/Allergies: ______________________ Doctor’s Name: _______________________
Person to Notify in Emergency (include telephone # if different from above)
I (name) ____________________am interested in: Coaching ________ Assistant Coaching _______
Contact me at phone ______________ email _________________
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 or 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. It is possible that pictures will be taken during programs. I
agree that pictures taken during program hours could potentially be used for promotional purpose.
Grades K-3: Fees: $75.00 (INCLUDES T-Shirt) by November 9th, $85.00 after November 9th.
Grades 4-11 Fees: $100 by November 9th, $110 after November 9th.
Additional Fee: $25 Reversible mesh jersey (required one time fee) SIZE_______
CHECKS PAYABLE: Town of Rutland
MAIL TO: Rutland Recreation, 250 Main St. Rutland Ma 01543
* All players must register through the Recreation Department
* Late registrants will be placed on a wait list If necessary.
For office use only: Date Received Check # Amount