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.
Funded by New York State Office of Children & Family Services
Youth Basketball Ages 9 -21
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? ______
Ethnicity: White ___ Black___ Hispanic___ Native American__ Asian __Other___
Telephone # Home: ____________Work:_______________ Cell: _______________
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: $50.00 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
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