NORTH BROOKFIELD YOUTH BASKETBALL/ PLAYGROUND COMMITTEE SUMMER BASKETBALL PROGRAM The North Brookfield Youth Basketball League and the North Brookfield Playground Committee will be organizing a summer basketball program for boys and girls who will be in 1st grade through 6th grade in the fall of 2009. There will be three divisions, 1st & 2nd graders will play on Monday’s, 3rd & 4th graders will play on Tuesday’s and 5th and 6th, on Wednesday The program will begin on Monday July 13th and run thru August 19th. The format of the program will be determined by the number of players we have in each division. A $10.00 registration fee will be charged per child. Dead line for registration is July 3rd Please complete the bottom of this form and send along with $10.00 to: North Brookfield Summer Basketball C/O Richard LeBlanc 58 Shore Road. ,N.B 01535 Contact Andy Caron at 508-867-7600 or Richard LeBlanc, with questions . (Please make checks payable to North Brookfield Summer Basketball) Boy______________ Girl_____________ NAME: _______________________________________________ MAILING ADDRESS:_____________________________________________ PHONE: ______________________________________________ D.O.B: ______/________/_________ GRADE IN SEPT 2009____________________________________ E-MAIL ADDRESS_____________________________________ PHYSICIAN:__________________________________________ HEALTH PROBLEM OR ALLERGIES: _________________________ I would be interested in helping by Coaching_______, Officiating________, Scoring________ Name ____________________ I do hereby release, absolve, indemnify, and agree to not hold the North Brookfield Playground Committee or the Town of North Brookfield, and its organizers, supervisors, coaches and participants responsible for any injury from playing sports and transporting my/our child whether the result of negligence or for any other reason. PARENT’S SIGNATURE: ________________________________ DATE: __________