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2023-24 Pittsville Youth Basketball Registration

To complete the registration process, you'll need to do two things by Friday, October 13, 2023:


1) Fill out and submit this electronic form, which includes a parental permission waiver and a confirmation that you will be paying the $25 registration fee. 


2) Pay the $25 Registration Fee.  Deliver cash or check to the Youth Basketball basket in the elementary school office (make checks payable to Pittsville Youth Sports).  If cost is an issue, please indicate on the registration form that you would like to be contacted about a scholarship in place of the registration fee.  We want to emphasize that all Pittsville children grades 3 through 6 are welcome. 


If you have any questions regarding the youth basketball program or are interested in helping coach our 3rd grade boys team, please email pittsvilleyouthbasketball@gmail.com.

Thank you, we look forward to a great season!
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Email *
Player Name (Last, First) *
Team *
Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian Name(s) *
Parent/Guardian Email Address *
Primary Phone Number *
Home Address *
Alternate Parent/Guardian Phone Number(s)
Emergency Contact Name *
Emergency Contact Phone Number *
Health Plan - Insurance Company
 *
Hospital / Clinic
 *
Family Physician
 *
I will pay the $25 registration fee by: *
Required
In case of accident, injury or any other emergency to my child named above, and in event a parent/guardian is unable to be contacted, I hereby authorize emergency medical treatment by the family physician or by another qualified, licensed physician who is available.  **Please enter parent/guardian signature and relationship to player.** *
I/We hereby give my/our approval to participate in any and all Pittsville Youth Sports basketball activities.  I/We acknowledge that there are certain risks and hazards incidental to such participation, including transportation to and from the activities.  I/We in our own right and on behalf of our child do hereby waive, release, absolve, indemnify and otherwise agree to hold harmless the local league, organizers, sponsors, supervisors, coaches, participants, or other agents and also persons transporting my/our child to and from such activities from any claim for damages arising out of injury to my/our child as a result of negligence or for any other cause.  I/We will return any uniforms or equipment in the same condition as when issued, except for normal wear and tear.  **Please enter parent/guardian name as signature.** *
A copy of your responses will be emailed to the address you provided.
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