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____________________