Lyme Parks and Recreation Winter Basketball League Registration Form

November 22nd, 2011

Lyme Parks and Recreation Winter Basketball League Registration

Mail toLymeTown Hall(480 Hamburg Rd.,Lyme,CT.06371)  Please do not send in to school.

Childs Name_____________________________________________________________

Grade _________________ Age ________________ Birth date ____________________

Address_________________________________________________________________

Parent/Guardian___________________________________Email___________________

Phone ______________________________(home)________________________(work)

Would you like to coach?  _________ Assist? ___________ Other? _______________

In case of emergency, please list the name of a contact person in case the parent cannot be reached: Name__________________________________________Phone____________________

Please add any additional information regarding availability and carpooling on the back to help us place your child on the appropriate team.

Do you give permission for simple first aid to be administered to your child?  Yes____  No____

Does your child have any medical conditions (i.e. allergies, asthma, bee stings, etc.) that we should be aware of? Yes_________ No___________

If yes, please specify_____________________________________________________________

Is your child presently taking any medications? Yes_________ No___________                           

If yes, please specify_____________________________________________________________

In consideration of the acceptance of my child in the Town of Lyme Recreation programs, I, for myself, executors, administrators, and assignees, and my child’s executors, administrators, and assignees do hereby release and discharge the Town of Lyme and the Town of Lyme Recreation Commission, their employees, agents, officials, counselors, lifeguards, coaches, and other program personnel from any and all claims arising or growing out of my child’s participation in said program.  I attest and verify that I have full knowledge of the scope of this program and activities to be conducted in it and that my child is physically fit, sufficiently trained and qualified to participate in various activities. 

Parent’s Signature___________________________________ Date________________

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For Lyme P&R’s use:      Paid:_________________ Level/Team____________________