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2018-2019 Northeast PTA/Ithaca Youth Bureau Basketball Registration
THE OBJECTIVE OF THIS PROGRAM IS TO ALLOW AS MANY STUDENTS AS POSSIBLE TO PLAY BASKETBALL AND LEARN ABOUT TEAM SPIRIT. If you have questions, please contact Laura Dolch at laurawdolch@gmail.com

If you are registering more than 1 child for this program, please complete a new form for each child.

This form and payment are due by November 16th, 2018 by the end of the school day. This is the absolute LAST day that forms and payment will be accepted.
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Last Name (student) *
Your answer
First Name (student) *
Your answer
Team - All teams will start practice the week of December 10, 2018. *
T shirt size *
Shirt number for back of shirt (if left blank, one will be assigned to you)
Your answer
Child's Birthday *
MM
/
DD
/
YYYY
Child's Age *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian second email address (if you have one)
Your answer
Parent/Guardian Address *
Your answer
Parent/Guardian phone number *
Your answer
Are you willing to help with any aspects of the basketball program? *
Emergency Contact Name *
Your answer
Emergency contact phone number *
Your answer
Does your child need any special assistance to be able to participate in the basketball program? If so, please explain.
Your answer
Payment - check one box. Your child's place on a team is not final until your payment is received by the basketball coordinator. Send cash or check (payable to NE PTA) to school in an envelope marked "Basketball" by 11/16/2018. If you are registering more than one child, you can sent in one payment (cash or check) for all children combined. *
I acknowledge that participation in the Elementary School Basketball program entails certain risks and dangers. I also understand that the presence of qualified instructors does not relieve participants of the responsibility for their own safety. I agree to exercise caution and good judgment in the program. Note: this is not to be interpreted as a waiver of participants' legal rights.I give permission for the Ithaca Youth Bureau to use photos/video/name of my child to promote community awareness. (if not please send a note with your payment saying this). *
Required
Demographic Info - for Ithaca Youth Bureau (optional) My child identifies as:
Residency Info - for Ithaca Youth Bureau. My child lives in the: *
These materials are neither sponsored nor endorsed by the Board of Education of the Ithaca City School District, the superintendent, or this school
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