Athlete's Name *

First Name

Last Name

My athlete has medical insurance coverage. *

Yes, my athlete is covered by medical insurance, and I understand this is a requirement to participate in any PY Youth Basketball Program.

Guardian Name *

First Name

Last Name

Phone Number *

(###)

###

####

Emergency Contact (cannot be the same as guardian listed above) *

First Name

Last Name

Emergency Conact Phone Number *

(###)

###

####

Clinic Sessions Attending *

$10/clinic $40/all clinics Remember, if your athlete attends every single session, your money will be refunded in October.

June: Shoot the Lights Out ($10)

July: Fine Tune Your Footwork ($10)

August: Position Play ($10)

September: ($10)

October: ($10)

ALL ($50)

I plan to pay via... *

Venmo

Paypal

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

I have spoken with a PY Youth Basketball representative about a scholarship.

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. *

I have read the above statement, and I 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.