Player's Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

My daughter... *

...has her own regulation size (28.5) girl's basketball in our home and DOES NOT wish to receive another basketball.

...has her own regulation size (28.5) girl's basketball in our home and wishes to receive an additional basketball.

...DOES NOT have her own regulation size (28.5) girl's basketball in our home and wishes to receive one.

Shirt Size *

Youth Small

Youth Medium

Youth Large

Adult Extra Small

Adult Small

Adult Medium

Adult Large

Adult Extra Large

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's/Guardian's Name *

First Name

Last Name

I understand that PY Youth Basketball is in great need of volunteers. I am interested in volunteering. (Check the areas you are interested in.) *

Coaching

Board Member

Small Jobs (Organizing Paperwork, Helping with Registration, etc.)

Fundraising

I cannot volunteer at this time.

Phone *

(###)

###

####

Parent's/Guardian's Name

First Name

Last Name

Phone

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

As a Parent/Guardian of the child aforementioned in this form, I fully understand and acknowledge that (a) risks and dangers exist in use of basketball equipment and participation in basketball activities; (b) my child, or children's, participation in such activities and/or the use of such equipment may result in their injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, eye injury, blindness, heat stroke, heart attack, death or other ailments that could cause serious disability; (c) these risks and dangers may be caused by the negligence of participants, the negligence of others, accidents, breaches of contract, the forces of nature or other causes. These risks and dangers may arise from foreseeable or unforeseeable causes and (d) by my child's/children's participation in these activities and/or use of equipment, I hereby assume all risks and dangers and all responsibility for the losses and/or damages, whether caused in whole or in part by the negligence or other conduct of the owners, agents, officers, Penn Yan Youth Basketball Board of Directors, or by any other person. I, on behalf of my child/children, myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify the Penn Yan Youth Basketball Board of Directors and it's owners, agents, officers, and volunteers from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services, or otherwise which may arise out of my child's use of basketball equipment or my child's/children's participation in basketball activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the owners, agents, officers, or the Penn Yan Youth Basketball Board of Directors. I HAVE READ THE ABOVE WAIVER AND BY SIGNING IT, AGREE IT IS MY INTENTION TO EXEMPT AND RELIEVE THE PENN YAN YOUTH BASKETBALL BOARD OF DIRECTORS FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OF ANY OTHER CAUSE. *

Yes, I read the above statement and agree.

I give permission for my daughter's photo to be taken and used for PY Youth Basketball Promotions, Website and Social Media Sites. *

Yes, I give permission.

After signing this form, I plan to pay via... *

Check (Mail to: PY Youth Basketball, PO Box 110, Penn Yan, NY 14527)

Venmo (click button above)

Paypal (click button above)

I have spoken with a PY Youth Basketball Representative and plan to utilize a scholarship.