IMMACULATE CONCEPTION PARISH CYO REGISTRATION FORM - Basketball 2019
Please complete the registration and Insurance information requested.

Registration Fees:

$55- if you only have Kindergarten through 2nd grade or High School (only)

$70 for 1st child

$35 for 2nd child

$0 for third and/or additional family members.

PAYMENTS CAN NOW BE SUBMITTED THROUGH VENMO! PLEASE SEND WITH YOUR CHILD'S NAME AND SPORT AS THE SUBJECT

VENMO: @ImmaculateConception-CYO

PLEASE MAKE CHECK PAYABLE TO: IC CYO
IC CYO Registration Form *
Child's Name (First, Last)
Your answer
Child's Grade *
Child's Date of Birth *
Your answer
Parent/Guardian Name (First/Last): *
Your answer
Phone/Mobile Number: *
Your answer
Emergency Contact Name: *
Your answer
Emergency Contact Phone #: *
Your answer
Parent/Guardian E-mail address: *
(for general communications)
Your answer
*
Activity your child will participate in:
Required
In order to participate in the CYO program, your child must be enrolled in CCD or the Immaculate Conception Academy. Please choose one of the following: *
Parent/Guardian Signature:
Your answer
As a parent and/or legal guardian, I(we) remain legally responsible for any personal actions taken by our(my) child. In consideration for my(our) child’s participation, I(we) and my(our) child, agree and understand that we assume the risks inherent in the program, and with full knowledge of the risks, we, and our heirs, successors and assignees, agree to release and to hold harmless and defend Immaculate Conception Academy and Parish, and the Diocese of Allentown, Bishop John O. Barnes, and all of their employees and representatives, including chaperones, volunteers or any other representatives associated with the program(all of whom are collectively referred to as the Diocese) from claims from or related to my(our) child’s participation, or in connection with any illness or injury(including death) or cost of medical treatment in connection therewith, and I (we) agree to compensate the Diocese for reasonable attorney’s fees and expenses incurred by the Diocese in any action brought against the Diocese as a result of such injury or damage, unless such claim arises from the negligence of the Diocese. *
Required
I/we hereby warrant that to the best of my(our) knowledge, my(our) child is in good health, and I(we) assume all responsibility for the health of my child. EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I(we) hereby give permission to transport my(our) child to a nearby hospital for emergency medical or surgical treatment. I (we) wish to be advised prior to any further treatment by the hospital or doctor. *
Required
MEDICAL INSURANCE INFORMATION: *
HEALTH PLAN CARRIER?
Your answer
MEDICAL INSURANCE INFORMATION: *
HEALTH PLAN Group #
Your answer
MEDICAL INSURANCE INFORMATION: *
HEALTH PLAN ID #
Your answer
SPECIFIC MEDICAL INFORMATION: *
ALLERGIES:
Your answer
SPECIFIC MEDICAL INFORMATION: *
OTHER MEDICAL CONDITIONS THAT THE COACH SHOULD KNOW ABOUT:
Your answer
PARENT/GUARDIAN SIGNATURE and Date *
Your answer
Participants/Parent’s CODE OF CONDUCT *
1. I will treat opponents with respect, shake hands prior to and after contests. 2. I will respect the judgment of the officials and abide by the rules of the contest. 3. I will accept the responsibility of representing the school and parish by displaying positive behavior at all times. 4. I will play/cheer in a positive manner, reflecting Christian values. 5 I will attend Mass on a regular basis and attend Mass together once as a team and participate in a team service project. 6. I will support the coaches in an attempt to develop the team in a faith community. Penalties: 1. Any player or parent ejected from a game or match because of unsportsmanlike conduct will be suspended from the next game. A review by the IC CYO board will determine if the player/parent is eligible to play or attend games for the remainder of the season. 2. Any player or parent who physically or verbally abuses another player, coach, participant or official may be suspended from play/attending games for the remainder of the season. The IC CYO board will review, on a case by case basis, this decision.
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy