HAMDEN FATHERSí BASKETBALL ASSOCIATION, INC.
HAMDEN DEPARTMENT OF PARKS & RECREATION
Circle Boy Girl Age ________
††††††††††††††††††††††††† †Last††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† First
Address __________________________________† Zip† _______†† Phone (1)_____________
Month Day Year
Do you have any physical problems? _____________________
Member of ______________________________________________ team last year.
(If new player, leave blank.)
We hereby give our permission for our child named above to participate in the Basketball Program, and accept full responsibility.† We also assume all the risk and hazards incidental to the conduct of the activities, including transportation to and from activities.
In order to compensate for any large medical expenses caused by injury to your child, the Basketball Association has procured an accident policy with a deductible.† You are, however, required to first use any insurance you may have, such as Blue Cross, PHS, etc., in order that we may continue to provide this extra coverage at a low rate.† The parentsí signature on the registration card denotes acceptance of this insurance coverage as heretofore stated.
Has Birth Certificate been checked? _____††††† ____††† ______________________(Parent)
Has registration fee peen paid? _____††††† ____
Does parent wish to assist in activities? _____††††† ____ ______________________(Interviewer)