Town Of Rochester Youth Commission
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
Funded by New York State Office of Children & Family
This program does not deny services to participants regardless of race, creed, color, national origin, sex, or disability.
Youth Basketball Ages 7-8
2008-2009 Registration
"You must bring your birth certificate!"
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!)
Telephone # Home: ____________Work: ______________ Cell: _______________
Ethnicity: White ___ Black___ Hispanic___ Native American__ Asian __Other___
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: $40.00 PER CHILD
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 Commission
Date of payment |
Method of payment (include Check No.) |
Amount |
|
|
|
| 
