Columbus Recreation REGISTRATION FORM / 3rd grade boys’ basketball PARTICIPANT INFORMATION: Please print legibly Last Name: Gender:  Female First Name:  Male Age: _ ___________ T-Shirt Size please circle below YS _____ YM _____ YL _____ YXL _____ AS _____ AM _____ AL _____ AXL _____ AXXL _____ Grade attended: _____________________ Home address: City: State: Postal/Zip Code: Country: Telephone: cell: Parent email: (Include area code with telephone) Please list ADA Accommodations needed / Allergies if any _____ Is your child on any medication? No Yes if yes, please specify: Mother’s name: Father’s name: Mother’s day phone: Father’s day phone: Mother’s cell: Father’s cell: _________________ Person’s authorized to pick up child: ________________________________________________ Other Dismissal Arrangements_________________________ Emergency contact*: Relationship: Phone: Payments: Payments may be paid by cash or check or online with credit card or at the Recreation Center. Make the check payable to: City of Columbus Recreation (CRD) Fees and dates:  Week of January 4th is the start date  Week of February 8th is the end date  Definite practices will be set up after coordinating gym times with CES Athletic Director Schedules will be sent via email to parents from Amy Jo Meyers at this time  Registration fee: $25.00  Includes a T-shirt Contact Information For more information, contact Amy Jo Meyers, Recreation / Aquatic Director Columbus, WI 920.623.5936 Email: [email protected] PARENT OR GUARDIAN SIGNATURE DATE I understand that payments are due before the start of a new session. We do not provide make-ups or refunds for any days missed for any reason. Please do your best to come to your scheduled program. REQUIRES PARENT’S SIGNATURE: You have our permission, in the event of an emergency and in case we are unavailable, to authorize any physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my child_______________________________________________ as they may deem advisable. Parent/Legal guardian name________________________________________________Date_______________ Parent/Legal guardian Signature_____________________________________________Date_______________ Student Allergies________________________________________________________________ Student Medical Problems_______________________________________________________________ Doctor______________________________ Phone number____________________________________ I hereby give permission to Columbus Recreation Department to photograph and/or videotape the student for educational or promotional purposes. ________ (Initial) PARENT STATEMENT I hereby state that (participant’s name) ___________________________________________ is in good mental and physical health condition to participate in the activities provided by Columbus Recreation Department including but not limited to all aspects of cheerleading, tumbling, and dance training, baseball, basketball, soccer, volleyball, cross country, track and softball or competition. I am fully aware that any activity involving motion, height or athletic activity creates the possibility of serious injury. I hereby release Columbus Recreation Department, its employee and its staff from liability to the above named athlete, of the person claiming through him/her, arising from injury to the person or property of the above named athlete occurring in the premises of Columbus Recreation Department, including any event sponsored or sanctioned by Columbus Recreation Department and or travel to and from such activities. Parent Signature_____________________________________________Date___________