East Irondequoit Athletic Association (EIAA)

East Irondequoit Athletic Association (EIAA)

Travel Basketball Registration

2014- 2015

Boys Boys

Hard Work; Determination; Heart

Youth Travel participation is based on Team Tryouts(boys only). Travel Teams are limited and based on gym availability and adult volunteers.

Participant Information

Players Name: ______Date of Birth: ____/____/______

Address: ______City: Rochester, NY Zip: ______

School (circle): EIMS DE LP IG HR *Must attend a school within East Irondequoit School District

Grade (circle): K 1 2 3 4 5 6 7 8 Best Evenings to Practice (M,T,W,R,F): ______

Travel Registration Fees (circle team bracket): Fee includes a $10.00 non-refundable process fee. / Returned check fee is $20.00.

3/4 Grade $130.00 5/6 Grade $185.00-Personalized Jersey 7/8 Grade $185.00-Personalized Jersey

Website: www.eiaasports.org

Parent/Guardian Information

Parents/Guardian Names: ______

Parents E-mails: ______

Home Phone: ______Cell Phone: ______Work Phone: ______

Emergency Contact Name: ______Phones: ______

Health Insurance: ______Health Insurance #: ______

Doctor’s Name: ______Phone: ______

All Parents/Guardians will be required to volunteer at EIAA Basketball Home Tournaments and/or Home Games

GENERAL/MEDICAL RELEASE — MUST BE SIGNED BEFORE PARTICIPATION

I/We hereby acknowledge that participation in basketball competition carries with it a hazard. I/We therefore, release the East Irondequoit Athletic Association, it’s teams coaches, the officers, the Town of Irondequoit, NY, and the East Irondequoit Central School District, as well as tournament hosting club’s officers, tournament site municipalities and school districts from any liability in the event of injury or illness suffered while playing for the East Irondequoit Athletic Association, in league or tournament games.

If the above named basketball player should become ill or sustain an injury, and a parent or guardian cannot be contacted, permission is granted to call a licensed physician for treatment, or to transport the above named participant to a hospital emergency room for treatment.

I/We certify that the above information regarding my/our child is true and correct.

Parent/Guardian Signature: ______Date: ______

FOR OFFICE USE ONLY EIAA Basketball Representative Accepting documents: ______

Paid by CHECK #: ______Check Amount $: ______/ Paid by CASH Amount $: ______

Additional Notes: ______