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Diocese of Rochester Holy Trinity Parish 2012-13 CYO BASKETBALL REGISTRATION Return completed (both sides) registration form

with check *
Childs Name: (Please print) _________ __________________________________________________________ Age: _______ Date of birth: _____/_____/_____ Male ___ Female___

Grade in Sept __________

School________________________________________________________

Street: ________________________________________________ City: _____________________ Zip: ________ Parent 1 Name (Full): _________________________________ Parent 1: Home Phone: ____________________ Work Phone: ______________ Cell Phone _________________ Parent 1: E-mail __________________________ Parent 2 Name (Full): _________________________________ Parent 1: Home Phone: ____________________
Work Phone: _____________ Cell Phone _________________ Parent 2: E-mail _________________________

Eligibility Statement
Is your family registered in Holy Trinity? Yes _____ No ______ (Preference is given to parishioners who have registered prior to or during the in-person registration weekend, September 22nd-23rd) If not at Holy Trinity - Parish and Location: __________________________________________________

Parent Volunteer Needs


(We really do need you! Teams will not choose a practice night until they have a head coach) Head Coach ______ Assistant Coach ________ C.A.S.E. Training Completed: ___Yes ___No Referee (3rd/4th only)_______ Scorers Table____________ Year and Parish of Training: ___________________

Each players family is expected to take turns manning the admissions table and concession booth

Fees**
Fees for 2012 Season: 3rd & 4th Grade - $60.00 7th & 8th Grade -$90.00 Checks payable to Holy Trinity Sports For any questions regarding registration, please read the frequently asked questions before contacting Leslie Pawluckie: wpawluck@rochester.rr.com * In person registration after all Masses on September 22nd-23rd. Forms can also be dropped off at the parish office during regular office hours, or mailed to the parish office. ** Discount given for children of head coach Contact Leslie Pawluckie 5th & 6th Grade - $75.00 High School - $100.00

Date Received: ___________

Paid: ____

Check #: ______

HEALTH HISTORY
Health History: Please list any medical conditions that might affect your son s or daughters participation in this program. Please include any medications currently taken by your child on a regular basis. If your child has a condition affecting their participation in the program, your physician must provide written authorization indicating approval of their participation. Emergency Contact (If Parent not Available) _________________________ Relationship __________________ Day Phone ________________ Evening Phone __________________ Cell Phone _________________________ Insurance Carrier: ______________________________ Policy Number: _________________________________ Primary Care Physician: ____________________________ Physician Phone:______________________________ Any allergies or special needs/concerns/dietary restrictions, health concerns: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Any medications (perscription and/or non-perscription) currently takinginclude dosage: ____________________________________________________________________________________________

HEALTH RELEASE STATEMENT Release Statement: I give permission for my child to be transported in a privately owned vehicle or emergency transportation for medical emergencies and for the release of medical records to an attending health care professional in case of injury or illness. I understand that every effort will be made to contact the parent or guardian. If one cannot be contacted, I hereby give my permission for a qualified physician to secure proper treatment for my child. I certify that my child is in good health and has no limitations other than those I have listed, which may predispose him/her to risk during particiaption in the program. I authorize the Diocese of Rochester to provide this registration form to the Athletic Director and/or the Coach and/or coaches of my childs team. My signature confirms that I have read the CYO Athletics philosophy and I give my permission for my child to participate in the program and for the Athletic Director and/or Coach to have a copy in his/her records. I hereby release the Diocese of Rochester and all its affiliated entities, including its employees, volunteers and the parish sponsor for any and all liability for any damages suffered as a result of or relating to my childs particiaption in this program of CYO Athletics. Parent Signature/Guardian Signature: __________________________________________ Date: ___________________

MEDIA RELEASE I give permission for the Diocese of Rochester to make use of pictures of my son/daughter for information advertising purposes only: Please check one of the following: In conjunction with the photographs, slide, audio tape or videotape, I also give my permission for the Diocese of RochesterCYO Athletics to identify the person(s) either verbally or in writing. I request no Identifiable information pertaining to the above-named person(s) be used in conjunction with the photograph, slide, audio tape or videotape. I hereby release Diocese of Rochester and all its affiliated entities, including its employees, volunteers and the parish sponsor for any and all liability for any damages suffered as a result of or relating to the use of any photograph, slide, videotape or audio tape, of your child done in accordance with the foregoing.verbal or written material. Parent/Guardian Signature: ___________________________________________________ Date: __________________

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