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YMCA of Mount Vernon
Pre-K-8th Grade Basketball Registration Form
Child’s Name: __________________________
Birth Date: ______________
School:_____________________________Present Grade: ________________
Parent(s) Name ___________________________Phone #__________________
*Please put the best phone number for coaches and/or staff to contact you.
Address: ____________________
City: ______________ Zip: __________
Parent(s) e-mail: _____________________ _____________________________
How did you hear about YMCA basketball?____________________________
Jersey Size (Circle one)
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Special Requests—(Please understand every attempt will be made to honor your request, but some circumstances may not allow a request to be granted.): _______
__________________________________________________________________
Credit Card: Visa/Discover/MC # ______________ Exp. Date _________
Should your child desire not to participate at the time the program is sched-
uled to begin (the day before the first game or session) you will receive a re-
fund minus a $20.00 handling fee. This request must be in writing and will take up to two weeks for processing. Should your child drop out of a program after the first game or session, you will not receive a refund. All requests will be reviewed and approved by the program director.
_______________________________
________________________
Parent / Guardian Signature
Date
______________ YES, I want to volunteer and coach my son or daughter’s team. Name: _____________________________ Phone Number: _______________
E-mail Address____________________________________________________
______________ YES, I want to sponsor a youth basketball team for $200. Company Name___________________________________________________
Contanct Person_________________________Phone Number_____________
E-mail____________________________________________________________
____I would like to pay now. ________Please Invoice me PARTICIPANT WAIVER FORM:
I accept that the YMCA of Mount Vernon is only providing me and/or my minor child an opportunity to use an Athletic Facility for recreational use. In consideration for the privilege to use this facility, I agree to assume all risks for myself and/or my minor child and release and hold harmless the YMCA of Mount Vernon, its staff, agents, owners, officers, manufacturers of equip-
ment and materials, property owners, lease holders, league directors, coach-
es, team managers, officials, sponsors and any other having an interest in the facility from all liability, negligence, causes of action, claims, demands and damages of every kind which may arise out of my participation and/or my minor child’s participation in any and all activities at this facility.
I will familiarize myself and/or my minor child (if applicable) with the rules of the game and/or scheduled event/activity and the facility policies and will, to the best of my ability, have him/her play under control and avoid injury to self and other persons using the facility. I have carefully read, understand and accept all the policies of the YMCA of Mount Vernon, specifically de-
scribed in the YMCA Newsletter and in the Parent Packet.
All adult participants must sign this waiver form to actively participate in programs offered at the YMCA of Mount Vernon, including coaching. For participants under age 18 the parent or guardian of each under aged partici-
pant must complete this waiver form. The Coach/Team Managers submission of the team roster only indicated their willingness to accept responsibility for the conduct and sportsmanship of each player on the team whose name ap-
pears on that roster.
BY SIGNING, I ACCEPT AND UNDERSTAND THIS WAIVER FORM AND THE FA-
CILITY POLICIES DESCRIBED IN THE YMCA’S NEWSLETTER INCLUDING THE REFUND AND CANCELLATION POLICIES FOR TEAMS AND/OR INDIVIDUALS. I FURTHER ACKNOWLEDGE THAT IF I, OR MY MINOR CHILD IS INJURED OR PROPERTY IS DAMAGED DURING MY/HIS/HER PARTICIPATION I MAY BE FOUND BY A COURT OF LAW TO HAVE WAIVED MY RIGHT TO MAINTAIN A LAWSUIT AGAINST THE YMCA OF MOUNT VERNON ON THE BASIS OF ANY CLAIM FROM WHICH I HAVE RELEASED THEM HEREIN. I HAVE HAD SUF-
FICENT TIME TO READ THIS DOCUMENT IN ITS ENTIRETY. I HAVE READ AND UNDERSTAND IT AND I AGREE TO BE BOUND BY ITS TERMS. I CAN RE-
QUEST A COPY OF THIS FORM AT ANY TIME.
THE TERM OF THIS WAIVER IS INDEFINATE, UNLESS WITHDRAWN, IN WRIT-
ING, BY THE SIGNING PARTICIPANT OR THE PARENT ON BEHALF OF A MI-
NOR PARTICIPANT.
_____________________________________________
PARTICIPANT/PARENT SIGNATURE (if participant is under 18)
ATHLETES CANNOT BE REGISTERED OR BEGIN PROGRAM PARTICIPATION WITHOUT SUBMITTING BOTH A SIGNED REGISTRATION FORM AND A SIGNED SPORTSMANSHIP PLEDGE FORM FOR EACH ACTIVITY.
After reading the YMCA of Mount Vernon Code of Conduct, in the case of a minor, both parents/legal guardians must sign below.
By signing this, I hereby pledge to be responsible for my words and actions while attending, coaching, officiating or participating in a sports event and shall conform my behavior to the YMCA of Mount Vernon Code of Conduct. I also agree not to hold the YMCA of Mount Vernon or a member of the sports organizations, league, and/or Board of Directors responsible for the conduct of any athlete, parent, coach, official, or other attendee present at a sports event. The YMCA shall incur no liability for limited or nonenforcement of this Code of Conduct.
YMCA PARENT SPORTS CODE OF CONDUCT:
YMCA sports programs play an important role in promoting the physical, social and emotional development of children. It is therefore essential for par-
ents, coaches, spectators and officials to encourage athletes to embrace the values of good sportsmanship. Moreover, adults involved in sports events should be models of good sportsmanship and should lead by example by demonstrating fairness, respect and self-control.
I therefore pledge to be responsible for my words and actions while attend-
ing, coaching, officiating or participating in a sports event and shall conform my behavior to the following code of conduct:
I will not engage in or encourage my child, or any other person, to engage in unsportsmanlike conduct with any coach, parent, player, participant, official or any other attendee.
I will not engage in or encourage my child, or any other person, to engage in any behavior which would endanger the health, safety or well being of any coach, parent, player, participant, official or any other attendee.
I will not smoke, permit my child, or encourage any other person, to smoke, or use drugs or alcohol while at a sports event and will not attend, coach, officiate or participate in a sports event under the influence of drugs or alcohol.
I will not engage in or encourage my child, or any other person, to engage in the use of profanity.
I will treat and encourage my child to treat any coach, parent, player, participant, official or any other attendee with respect regardless of race, creed, color, national origin, sex, sexual orientation or ability.
I will not engage in or encourage my child, or any other person, to engage in verbal or physical threats or abuse aimed at any coach, parent, player, participant, official or any other attendee.
I will not initiate, or encourage my child, or any other person, to initiate a fight or altercation with any coach, parent, player, participant, official or any other attendee.
I will maintain direct supervision of all nonparticipating minor attendees in my care before, during and after all sporting events.
YMCA PLAYERS CODE OF CONDUCT:
Players shall…..
Display good sportsmanship and team play at all times.
Follow the direction of the Coaching Staff.
Respect all, coaches, players, league officials, umpires, and spectators.
Make every attempt to be on time and ready to play for all games and practices.
Inform coaching staff in a timely manner when unable to attend practice or games.
Players shall not…
Use abusive or profane language.
Kick, hit, throw and object, trip, etc. to intentionally hurt a player, coach, referee, or YMCA staff (coach, referee, or YMCA staff has the right to determine if the inci-
dent was deliberate or not.)
Taunt or humiliate any other player, coaches, referees, or YMCA staff.
Question an official’s call.
Abuse, mistreat or mishandle any YMCA league equipment or property.
THE YMCA OF MOUNT VERNON REQUIRES THE FOLLOWING:
Coaches, athletes, parents and other attendees are representatives of the YMCA of Mount Vernon and, at all times, must present themselves in a positive, respectful and sportsman-
like manner.
I hereby agree that if I or my child fail to conform our conduct to the foregoing while attending, coaching, officiating or participating in a YMCA sports event I will be subject to disciplinary action, including but not limited to the following in any order or combina-
tion:
Verbal and or Written Warning issued by a YMCA Staff, YMCA Referee or YMCA Coach.
Immediate ejection from the sports event issued by a YMCA Staff, YMCA Referee or YMCA Coach.
Suspension or banning from multiple games issued by the YMCA Staff, YMCA Refer-
ee or YMCA Coach.
Season suspension or banning or multiple season suspension issued by the YMCA Staff, YMCA Referee or YMCA Coach.
No refund will be given if a child or parent is suspended or banned from a sporting league/
event.
______________________________________
Parent Signature
_____________________________________
Participants Name/Signature
___________________
Date
Emergency Medical Form
ATHLETE’S INFORMATION:
Last
First
Middle
Grade
Age
Date of Birth
TO PARENT OR GUARDIAN: To serve your child in case of an ACCIDENT OR SUDDEN ILLNESS, it is necessary that you furnish the following
information for emergency calls:
Parent/Guardian Name
Second Parent/Guardian Name
Home Address
Primary Phone Number
Work Address
Work Phone Number
Home Address
Work Address
Primary Phone Number
Work Phone Number
Please list two relatives or friends who will assume temporary care of your child if you cannot be reached:
Name
Address
Phone Number
Name
Address
Phone Number
HEALTH INFORMATION: List any relevant health conditions such as heart disease, diabetes, epilepsy, severe allergies, eye or ear problems, or
any chronic conditions, etc:
KNOWN FOOD ALLERGIES:
Preferred Doctor
Address
Telephone
I,
(parent/guardian first and last name), will not hold the YMCA of Mount Vernon responsible i
the event of accidents resulting in injury or death or loss of personal property.
Parent/Guardian Signature:
Date: