Port Dick Civic Association Registration - 2022
Please complete the form below for each child.  This means doing the form multiple times if you have more than one child.  Cost of membership is $75 per family and is only paid once.  Membership includes softball/baseball, soccer, youth cheer (football) and basketball for Pre-K through 6th Grade as well as any other activities that come up during the year.  Any questions can be sent to PortDCA@gmail.com.  Payment can be made through Venmo (@PortDickCivic) or checks mailed to 786 Chenango Street Binghamton, NY 13901.  Please let us know if you are interested in becoming a board member or have any ideas on community events.  Also, be sure to join our Facebook Group - Port Dickinson Community Association
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Email *
Parent 1 Name *
Parent 1 Email *
Parent 1 Phone Number *
Parent 2 Name (Optional)
Parent 2 Email (Optional)
Parent 2 Phone Number (Optional)
Emergency Contact Name *
Emergency Contact Phone Number *
Name of Child *
Date of Birth (Month/Day/Year) *
What grade is Child in during the 2022-2023 School Year? *
Sports Offered
Baseball & Softball (Spring & Summer)
Soccer & Cheerleading (Fall)
Basketball (Winter)
Baseball (TBall - Girls & Boys ages 4 & 5, Coach Pitch, Minors, & Majors - Boys ages 6-12) *
Softball (Coach Pitch, Minors, & Majors - Girls ages 6-12) **Girls ages 4 & 5 play TBall** *
Soccer ( Girls & Boys ages 4-12) *
Cheerleading (Girls grades K-6) *
Basketball (Girls & Boys ages 4-12) *
Volunteers are the only way our civic runs successfully, please consider helping out!
I am interested in volunteering...
I plan to pay the $75 Civic Dues via: *
*I/we, the parents/guardians of the above named children, hereby give my/our approval to participate in the Port Dickinson Community Association activities, including transportation to and from the activities. I/we do hereby waive, release, absolve, indemnify and agree to hold harmless the local Community Association, the organizers, sponsors, supervisors, participants, and persons transporting my/our children to or from activities, for any claim arising out of an injury to my/our children, except to the extent covered by accident or liability insurance.* I/we understand it is solely my/our responsibility to advise Port Dickinson Community Association coaches and teachers of any injuries or health risks, including food allergies, relating to my child and in said case, parents, not Port Dickinson Community Association coaches/teachers will assume responsibility for treating immediate food allergy reactions.*I/we will furnish the Port Dickinson Community Association with a birth certificate to verify child’s age if requested or needed.*I/we the parents/guardians do hereby pledge our assistance to the Port Dickinson Community Association whenever called upon.  I've read and understand this. *
COVID-19 Liability Waiver - I acknowledge the contagious nature of the Coronavirus / COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.  I further acknowledge that the civic associations of Hillcrest, Port Dickinson, Port Crane, Chenango Bridge, Nimmonsburg has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that the civic associations of Hillcrest, Port Dickinson, Port Crane, Chenango Bridge, Nimmonsburg cannot guarantee that I will not become infected with the Coronavirus / COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus / COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, coaches, players and their families.  I voluntarily agree to participate in civic events and sports and acknowledge that I am increasing my risk to exposure to the Coronavirus / COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while partaking in civic sports and events. I attest:*If I or my child experience any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell, that I will not partake in civic sports or events.*If I have traveled internationally, I will follow all state and federal guidelines in references to appropriate measures of self quarantine.*I have not been diagnosed with Coronavirus / COVID-19 and not yet cleared as a noncontagious by state or local public health authorities.*I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus / COVID-19.I hereby release and agree to hold the civic associations of Hillcrest, Port Dickinson, Port Crane, Chenango Bridge, Nimmonsburg harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses, and compensation for damage or loss to myself and/ or property that may be caused by any act, or failure to act of the civic associations or that may otherwise arise in any way in connections with any civic sports or events. I understand that this release discharges the civic associations of Hillcrest, Port Dickinson, Port Crane, Chenango Bridge, Nimmonsburg from any liability or claim that I, my heirs, or any personal representatives may have against the civic associations with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any civic sports or events. This liability waiver and release extends to the civic associations together with all civic volunteers. *
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