Winter Season registration

Please print allinformation.

Player’sName:Mother’s (or Guardian’s)Name:

HomeAddress:Father’s (or Guardian’s)Name:

Mother’sCellPhone: Age of Player on leaguedeadline (4/30/16): Father’sCellPhone: DateofBirth: Grade: HomeNumber: SchoolAttending: E-MailAddress:

**All players new to PAA Basketball must submit a copy of birth certificate with this registration form**

/ Rec Basketball6th Grade: / $125
$115
$115
$115 / Rec Basketball 2nd Grade:
1st Grade:
Kindergarten:
Rising Stars5th Grade: / $100
$100
$100
$140
5th Grade:
4th Grade:
3rd Grade:



Adult: / SmallLarge2XLOther
MediumX-Large3XL

** Players are responsible to purchase BLACK shorts **

Your child may be photographed during league play for use in PAA promotional materials.

I consenttothisI do not consent tothis.

Any coach will be asked to submit to a background check by a third party organization.

By signing at the bottom of the Medical Release section, you acknowledge you have read and agree to its contents and provisions.


VOLUNTEERS ARE NEEDED IN ALL AREAS – PLEASE CHECK THE BOX OF THE AREA(S) YOU CAN HELP THE YOUTH OF PAA:

 / Coaching /  / Concessions /  / Registration /  / Field Maintenance /  / Uniforms
 / Trophies /  / Field Permits /  / Umpiring /  / Fundraising /  / Sponsors

NAME & NUMBER WHERE YOU CAN BEREACHED:

** Please complete the Medical Release/Agreement on Page 2**

Questions: Contact Rob Smith (301-466-0700) or REGISTRATION DEADLINE – Winter: October 30, 2017

These materials are neither sponsored nor endorsed by the Board of Education of Montgomery County, the superintendent, or this school

As parent or legalguardianofIherebygrantpermissionformychildtoparticipateinBASKETBALLsponsored by the Poolesville Athletic Association. I understand this program is not responsible for any accidents. I understand by signing the form I accept all financial and medical responsibilities for mychild.

In addition, as parent or legal guardian I give my consent for emergency medical treatment approved by the team manager or other adult escort in case of serious illness or injury while participating in the Poolesville Athletic Association and related activities. I understand that this is to ensure prompt treatment. I have listed all allergies, special medication needs or physical or medical problems/concerns.

Name of MedicalInsuranceCompany: Physician’s Name: Phone#: HospitalPreference: LastTetanusshot: Emergency contact if parent cannot bereached:

Phone #:Relationship toparticipant:

Does your child have any of thefollowingallergies?□No Known Allergies

BeeSting PeanutTreeNutPollen/trees/grass/etc.

Drug (pleasespecifybelow)Food (pleasespecifybelow)Other (please specifybelow)

Please note additional medical information andsymptoms:

_

_

Parent/GuardianSignature:

** Please be sure to complete the bolded items on this page! **

Date:

Preferred Coach/player to placewith:

** Make all checks/Money Orders payable to: PAA Basketball **

** Returned checks will be subject to an additional $20 charge **

Mail all forms to Rob Smith, 17202 Lightfoot Ln, Poolesville, MD 20837

Questions: Contact Rob Smith (301-466-0700) or REGISTRATION DEADLINE – Winter: October 30, 2017

These materials are neither sponsored nor endorsed by the Board of Education of Montgomery County, the superintendent, or this school