CANDOR YOUTH ASSOCIATION
2014-2015
BASKETBALL
Registration/signups will be held Tuesdays, October 21st, October 28th, November 4th, from 630-8pm
in the Elementary cafeteria. The eligible age groups for this program are: grades K–6.
Please bring this form along with a $35 registration fee payable to “Candor Youth Association” to sign ups with you
(maximum of $60 per family). If you are unable to attend, please mail the form and payment to: Candor Youth
Association, PO Box 792, Candor, NY 13743. The final date to register is November 10th, after this date there is no
guarantee of participation. There will be a $30.00 fee for any returned check. The season will begin November 2014.
Child’s Name: __________________________________________ Birth Date: _____________ Grade: _________
Address: _____________________________ Email_________________ Cell: ___________ Texting: Yes
Male
Female
Residence:(check one) Village:
Town:
No
Current Age: _______
Ethnicity: ___________ (White, African American, Hispanic, Asian, American Indian, Other)
Optional: The purpose for this data is to assist Candor Youth Association in completing annual United Way forms
for program funding.
Note to Parents: If a child is playing modified (7th or 8th grade) basketball they are not eligible to play CYA
basketball.
In-House
KinderBall (kindergarten only)
Co-Ed Grades 1 & 2
Travel Boys
Grades 3 & 4
Grade 5*
Grade 6*
Travel Girls
Grades 3 & 4
Grade 5*
Grade 6*
*Grades 5 & 6 will be combined if not enough sign ups to field a team
Number of season’s applicant has participated in Basketball:_____ Check here if asking to “move up”
“moving up” decisions will be at the discretion of the Basketball Operations Manager)
(all
Shirt Size: _____ Pant/Short Size (for grades 3 & up):
Sizes Available: YS, YM, YL, AS, AM, AL, AXL, A2XL
Please volunteer your time!!!! Remember that without the help of our volunteers there would be no basketball
program.
I, ______________________________, am interested in the following position:
Head Coach
Assistant Coach,
Concession Stand,
Administrative duties,
Fundraising
I/We, the legal guardian(s) of the above named enrollee in the Candor Youth Association, Inc. sponsored activity herby give
approval to his/her participation in any and all activities. I/We assume all risks and hazards incidental to such participation
including transportation to and from activities, and I/We do here by release, absolve, indemnify and agree to hold harmless the
organizers, sponsors, supervisor, and participants for any claim arising out of any injury to my/our child. I/We accept the fact
that my/our child is responsible for all athletic equipment issued to him/her. I/We realize he/she is financially responsible for
any damaged or lost items not returned.
Candor Youth Association insures your child, however, it is understood that any injury by your child will first be processed
throughout the parent’s personal insurance. If this is not adequate, a claim can then be filed with the Candor Youth Association.
If medical bills are then in excess of the Candor Youth Association insurance of scheduled payments the difference is the
responsibility of the parent/guardian(s).
Parent/Guardian(s) signature: ________________________________ Date: __________________________
Medical history and emergency information must be completed on the reverse side of this form.
EMERGENCY INFORMATION
Parent/Guardian:
Home Phone:
Work Phone(s):
Cell Phone: _________________
Person to contact in case parent or guardian cannot be reached:
Name:
Phone:
Family Physician:
Phone:
Orthopedic Doctor:
Phone:
Hospital (Preference):
Medical History:
Asthma
Diabetes
Epilepsy
Allergies (list) _____________
*Note: Inhalers must be present at all practices and games, either with athlete or parent or given to coach.
Treatment used for the above: _____________________________________________________
Injuries in the last six months, such as knee, ankle, arm or concussion, explain:
Any additional information:
______________________________________________________________________________
Note to parents: If your child is injured while participating in a Candor Youth Association program, please
make sure the coach is advised immediately and ask for a copy of the accident report, which should be
filled out within 48 hours.
SPORTSMANSHIP POLICY
(Must be signed by parent/guardian and participant)
We hereby agree to abide by the Candor Youth Association Sportsmanship Policy, which prohibits the
display of poor sportsmanship to coaches, officials, players, families and spectators and includes, but
is not limited to, verbal harassment, profanity, threats, or improper physical contact. Upon the "first
offense," the player and/or parent will be verbally warned of their violation and may be asked to sit for the
remainder of the practice or game. Upon the "second offense," the player will be removed immediately
from the practice or game and will not be able to return until after meeting with the coach and
liaison. Parents will be informed in writing of their violation and agree to terms of continuing in the
program. Upon the "third offense," the player will be removed immediately and may be removed
permanently from the program, after a hearing with the liaison and other Candor Youth Association Board
of Directors members within five days. For serious infractions, including but not limited to physical
contact, the liaison may proceed directly to the "third offense" stage.
Parent signature: _______________________________ Date: ________________________
Participant signature: ___________________________ Date: ________________________
If you have any questions, contact James Floyd 607-237-2294 or [email protected]