Town Of Rochester Youth Department
PO Box 65
Accord, NY 12404
845-626-2115
Fax: 845-626-0141
Carol Dennin, Youth Director
Valerie Weaver, Asst. Director
Michael Smith, Sr., Basketball Director
This program does not deny services to participants regardless of race, creed, color, national origin, sex, or disability.
Youth Basketball
2011-2012 Registration
Name: _____________________________________________ Male ___ Female ___
Address: ____________________________________________ City/ Town/ State/ Zip: _______________________________
Date Of Birth: ______________ How old were you on August 1? _____ (Age counts on August 1, no exceptions!)
School: ____________________Grade: _____
Telephone # Home: ____________Work: ______________ Cell: _______________
Email: ___________________ (Please put your email address so we can contact you for cancellations and other game information.)
Has your Child participated in our program in the past? Yes or No
Does your Child participate in other basketball programs? Yes or No
If so, to what level? _______________
COST: AGES 7 & 8 $45 PER CHILD COST: AGES 9 – 21 $60 PER PLAYER
I, (please print) _____________________________________ being the parent or legal guardian of the above mentioned minor, do hereby certify that my child is in good health and may participate in the Basketball programs, I further authorize the director’s of the Rochester Youth Commission Basketball programs to act for me, using their best judgment, in any emergency requiring medical attention if a parent cannot be reached. The Town Of Rochester Youth Commission will not be held responsible for medical costs. I am responsible for my own child’s medical coverage.
Signature of Parent/ Guardian: _____________________________________________________________
Insurance Company & Policy Name: ________________________________________________________
Insurance Identification #: ________________________________________________________________
Emergency Contact #: ________________________________Physician’s Name/ # __________________
Make Check Payable to: Town of Rochester Youth Department
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