HAMDEN FATHERS’ BASKETBALL ASSOCIATION, INC.

AND

HAMDEN DEPARTMENT OF PARKS & RECREATION

 

Circle         Boy      Girl                                                          Age   ________

                                                                                              Registration 20___

   

Name __________________________________________________________(Please Print)

                           Last                                                                              First

 

Address __________________________________  Zip  _______   Phone (1)_____________

 

Date of Birth __________   School Attending ___________________         (2)_____________

                          Month  Day     Year

 

Email Address:_____________________________________

 

Do you have any physical problems? _____________________

 

Member of ______________________________________________ team last year.

                 (If new player, leave blank.)

 

We hereby give our permission for our child named above to participate in the Basketball Program, and accept full responsibility.  We also assume all the risk and hazards incidental to the conduct of the activities, including transportation to and from activities.

 

In order to compensate for any large medical expenses caused by injury to your child, the Basketball Association has procured an accident policy with a deductible.  You are, however, required to first use any insurance you may have, such as Blue Cross, PHS, etc., in order that we may continue to provide this extra coverage at a low rate.  The parents’ signature on the registration card denotes acceptance of this insurance coverage as heretofore stated.

                                                                 Yes         No

Has Birth Certificate been checked?        _____      ____    ______________________(Parent)

Has registration fee peen paid?                _____      ____

Does parent wish to assist in activities?    _____      ____    ______________________(Interviewer)