Rec Basketball –
nd
Grades – 2 – 8th
REGISTRATION FORM
Rec basketball is a fun program created to help our children learn sportsmanship
and the fundamentals of basketball. Each year we look forward to watching the
improvement of all athletes.
There is a minimal fee of $5 per child to participate. This is simply to help offset our
insurance costs that come along with hosting the program.
This year we are looking to model our Basketball program much like our soccer
program. Each team will have their own adult/volunteer/parent coach(s). We are now looking
for parents/adults that are willing to volunteer their time to coach a team and help this program
grow and succeed.
Please send forms and checks payable to Chesterfield Parks and Recreation to P.O. Box
175, Chesterfield, NH 03443 no later than Friday, February, 12th.
Student
Name:_________________________Grade:______Address________________
________City:_______ State:___Zip:______
Parent Contact: __________________________Phone:_______________
Parent Email : _____________________________________
T-shirt size: (PLEASE CIRCLE ONE)
Child:
Adult:
Small
Small
Medium
Medium
Large
Large
X-Large
X-Large
Please consider volunteering to Coach or be an Assistant
Coach. We need at least one coach per team.
Name:_________________________Grade Level:____________________
Home Phone:___________________Cell Phone:_____________________
Email:________________________________
REGISTRATION DEADLINE: THURSDAY FEBRUARY 12, 2016
Please email Dan Robel, drobel02@gmail.com with any questions
This is not a school sponsored activity
REC BASKETBALL 2016
SPORTS EMERGENCY CARD
Name: ________________________________________ DOB:____________________
Address:________________________________________________________________
EMERGENCY CONTACTS
NAME
RELATIONSHIP
PHONE #
1.______________________________________________________________________
2.______________________________________________________________________
Doctor:_____________________________________Phone #:_____________________
Dentist:_____________________________________Phone #:_____________________
Insurance:___________________________________Policy #____________________
Allergies (food or medicine) & any medical conditions we should be aware of:
_______________________________________________________________________
In case of an emergency or acute illness, I hereby authorize the Director to administer
first aid and to refer for medical treatment, including transportation and hospitalization,
as may be required under the circumstances.
Date:____________ Signature of Parent/Guardian:_______________________________
________________________________________________________________________
SCHEDULE:
2nd & 3rd Grades 4:30-5:30 p.m.
4th & 5th Grades 5:30-6:30 p.m.
6th, 7th & 8th Grades 3:15-4:30 p.m.
Tues 3/1
Wed 3/2
Tues 3/8
Thur 3/10
Tues 3/15
Wed 3/16
Tues 3/22
Thur 3/24
Tues 3/29
Thur 3/31
Tues 4/5
Thur 4/7
Tues 4/12
Thur 4/14
This is not a school sponsored activity
Chesterfield Parks & Recreation
Permission Slip
NAME OF
PARTICIPANT_____________________________________________________
My son/daughter has permission to participate in the Chesterfield Parks and
Recreation Department's program. I hereby waive, for myself and my child, the right
to assert any claim arising out of injury to the child due to participation in,
preparation for, or travel to and from any recreation sport or activity, I acknowledge
that participation in the sport or activity authorized comes with certain risks which
are hereby assumed. I relinquish any right which I or my child might otherwise have
for payment of medical costs or other losses beyond whatever insurance I may have.
I hereby authorize the Director, Recreation Program Leader, staff and volunteers of
the Chesterfield Parks & Recreation Department to act for me, according to their best
judgment, in any emergency requiring medical attention.
____________________________________________________________
Signature of Parent / Guardian
Chesterfield Parks & Recreation
This is not a school sponsored activity