Basketball Registration Form
This release and information form must be filled out completely with current information, agreed upon, signed, and turned in with the payment before the participant will be allowed to attend the program. KINDERGARTEN, 1ST, and 2ND GRADE HAS A $20 REGISTRATION FEE. 3RD-6TH HAS A $30 REGISTRATION FEE. This form is for the health and safety of the participant. If some questions do not apply, please indicate with "N/A".
Participant's Name *
Your answer
Grade
Your answer
Date of Birth *
mm/dd/yyyy
Your answer
Shirt Size *
Your answer
Gender *
Address *
Your answer
Identify any behavioral concerns and how to handle them *
Your answer
Limitations and Restrictions *
(Activity or Diet)
Your answer
Is the participant taking any medications? *
Your answer
If answered yes to previous question, please list medications. *
Your answer
Any medical conditions we should be aware of? *
Allergy? Asthma? Seizures? Diabetes? Other?
Your answer
Any other information that would be helpful to staff? *
Your answer
Parent/Guardian Name *
Your answer
Relationship *
Your answer
Address(if different)
Your answer
E-Mail *
(This is how we keep parents updated about games, practices, and cancelations)
Your answer
Mobile *
Your answer
Home Phone *
Your answer
Work Phone *
Your answer
Parent/Guardian Name (#2)
Your answer
Relationship
Your answer
Address (if different)
Your answer
Email
Your answer
Mobile
Your answer
Home Phone
Your answer
Work Phone
Your answer
Person to Notify in Emergency #1 *
Name and Contact Information
Your answer
Person to Notify in Emergency #2 *
Name and Contact Information
Your answer
Person to Notify in Emergency #3 *
Name and Contact Information
Your answer
Physician's Name *
Name and Phone Number
Your answer
Medical Coverage *
Your answer
Group ID # *
Your answer
Preferred Hospital *
Your answer
Please note that if you check "I do not understand for any of the statements below, your child will not be able to participate in the sport.
Media Release: I hereby grant the Bethlehem Recreation Department or other persons authorized (including newspapers or other media/social outlets) permission to record my child in photographs, videos and/or voice for use in television, film, radio, or printed media to further the aims of the Recreation Program in related campaigns and magazine articles, booklets, posters and in other ways they may see fit. *
Please Initial Below *
Your answer
Emergency Clause: In the event I cannot be reached in an emergency, I hereby give my permission to the employees and volunteers of the Bethlehem Recreation Department to secure proper medical care for my child as deemed necessary. This includes transportation by ambulance to an emergency facility. I understand that in releasing the Town of Bethlehem and the Bethlehem Recreation Department from any and all liability as a result of injury to my child that I am specifically releasing the Town and the Department from any and all liability for any injury to my child as a result of any negligent act by the Town or the Department, or its volunteers or employees. *
Please Initial Below *
Your answer
Behavior/Property Clause: I understand that no disorderly conduct will be tolerated by my child. Physical contact, verbal abuse, bullying, weapons or items that could be used as weapons will not be tolerated. Respect will be shown to staff and to others at all times. I will be notified if disciplinary actions warranting suspension or expulsion of the program. The Recreation Director reserves the right to dismiss a participant due to disorderly conduct without depending on the severity. In order to assist in the healthy development of my child, I give permission for the Bethlehem Recreation Department and the Bethlehem Elementary School staff to share/discuss information regarding my child’s performance with each other. *
Please Initial Below *
Your answer
I understand that personal belongings of toys, CD/MP3 players, hand-held games, etc. are not allowed at the BRD sports program. The Bethlehem Recreation Department is not responsible for said items including sports equipment if brought to the program. I release the Town of Bethlehem, it’s officers and the Bethlehem Recreation Department from liability as a result of personal and/or property damage incurred while participating in the Bethlehem Recreation Department sports program and documented Field Trips or transportation to and from activities or games. I understand my child is participating at my own risk. I understand that it is my responsibility to make payments as scheduled to continue my child’s enrollment. *
Please Initial Below *
Your answer
Release Clause: The undersigned hereby releases and holds harmless the Town of Bethlehem, it’s Council and any officers, employees or agents thereof from any and all claims, liabilities or demands whatsoever arising or claimed to have arisen out of the enrollment or participation in any program by the participant herein. *
Signature of Responsible Party, Relationship, Date Signed
Your answer
Please Turn in Payments to the Bethlehem Recreation Department. The participant will not be allowed to attend the program if both the registration and payment is not in. *
Please Initial Below *
Your answer
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