St.

Marys Minor Basketball 2013-2014 Registration Form

Family Information:
Last Name: Parents / Guardians Name(s):

Street Address:

P.O. Box:

Town:

Postal Code:

Phone:

Email:

Player Information:
First Name: Last Name: M/F Birthdate:
(dd/mm/yy)

Grade:
(Sept. 2013)

Fees:

Same as above Same as above Same as above

2013-2014 Registration fees: $50 per player

/ / / /

/ / / /
Amount Paid

$50

Paid By:

Cash

Cheque WAIVER

Registrar Initials:

_______________

This signed consent form allows the player named on this form to participate in all supervised activities in the Minor Basketball Association. I agree to release St. Marys Minor Basketball, Avon-Maitland School Board, Huron-Perth Catholic District School Board and Town of St. Marys from all claims, for damages from any accidents, or injuries, which are caused by, or arise from, participation, during any game, practice, or function of the program. I give permission to the Minor Basketball Association, Town of St. Marys and the media to photograph and/or videotape my child for use in any future promotional material without compensation. Privacy Statement: In accordance with the Municipal Freedom, Authorization and Protection to Privacy Act, personal information is collected under the authority of the Municipal Act 2001 P.S.O. c45, and will be used for the purpose of program development and operation. Questions may be referred to the Privacy Coordinator, 175 Queen Street West, St. Marys, N4X 1B6, and 519-284-2340. Personal information contained on this form is collected under the authority of the Freedom of Information Act and will be used by the Town Staff and Minor Basketball staff for the purpose of administering recreational programs for the Community Services Department of the Town of St. Marys. Questions regarding the collection of this information may be directed to the Community Services Department, 519-284-3272, during business hours.

_________________________ Parent/Guardian Name

________________________________ Parent/Guardian Signature

___________________ Date

Bring this completed form to a basketball registration night (October 10 or 17) with payment.

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