Registration Fee:
$65.00
KYA
PO Box 54
Keansburg, NJ 07734
2010
Keansburg Youth Association
INTERNET BASKETBALL REGISTRATION
FORM
Name _____________________________ Date of Birth ______________ Age ____
Address ________________________________ Phone ____________________
City ________________ State ___ Zip
______ School ________________ Grade ______
Sex
Male
Female
New Player Yes
No
Shirt
Size
Youth
Med Youth
Large Adult Small Adult Med
Adult Large Adult
X-Large
<<<<Medical Information>>>>>
Please list
any medical comments.
Medical Comments __________________________________________________________
I
______________________, hereby give my permission for my son/daughter
________________
To participate in the KYA
Basketball program. I fully understand that the KYA is not responsible for
charges
incurred as a result of injuries sustained in league or recreational
play beyond the limits of their insurance.
NO EMO COVERED. I agree to
pay a non-refundable registration fee for participation in this program.
As a parent or guardian of the above named child, I do hereby give my approval for
his/her participation in the
KYA Program. I agree to abide by all the rules and
regulations set forth by this organization while my child is participating.
All photos are the property of Keansburg Youth Association and should be
used with the best
interest of the children.
Number of Children
________
Amount Due ______
Cash _______ Check # _________
Registration Fee:
$65.00 per child.
Signature
__________________________
League Official __________________ Date _______
-------------------------------FOR
OFFICIAL
USE ONLY----------------------------