Registration Process --
Please complete all steps:
u Complete this Registration
Form (Deadline September 6)
PLEASE NOTE -- if you
are registering more than 3 participants, please complete an
additional form
v Make Payment
(Bottom of this page)
PLEASE NOTE -- Your
registration is NOT COMPLETE until your payment has been received.
u
Participant Child #1
First Name
Participant Child #1
Last Name
Age on December 31 2011
Gender
Male
Female
Birth Date (mm-dd-yy)
If no
additional participants from this family, skip to Address section.
Participant Child #2 First Name
Participant Child #2 Last Name
Age
on December 31 2011
Gender
Male
Female
Birth
Date (mm-dd-yy)
If no
additional participants from this family, skip to Address section.
Participant Child #3 First Name
Participant Child #3 Last Name
Age
on December 31 2011
Gender
Male
Female
Birth
Date (mm-dd-yy)
Please note that all participants
registered on this form
MUST reside at the SAME ADDRESS.
Street Address
City
ZIP Code
Township/Borough
Home Telephone
Alternate Phone
Email Address
Participant #1 School enrolled
2011-2012
Participant #1 Grade enrolled
2011-2012
Participant #1 T-Shirt
Size
----- Please select size -----
Adult Small
Adult Medium
Adult Large
Adult X-Large
Youth Small
Youth Medium
Youth Large
Youth X-Large
Participant #1 # years Paxton
experience
0
1
2
3
4
5
6+
Participant #2 School enrolled 2011-2012
Participant #2 Grade enrolled 2011-2012
Participant #2 T-Shirt Size
----- Please select size -----
Adult Small
Adult Medium
Adult Large
Adult X-Large
Youth Small
Youth Medium
Youth Large
Youth X-Large
Participant #2 # years Paxton
experience
0
1
2
3
4
5
6+
Participant #3 School enrolled 2011-2012
Participant #3 Grade enrolled 2011-2012
Participant #3 T-Shirt Size
----- Please select size -----
Adult Small
Adult Medium
Adult Large
Adult X-Large
Youth Small
Youth Medium
Youth Large
Youth X-Large
Participant #3 # years Paxton
experience
0
1
2
3
4
5
6+
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Phone
Parent/Guardian Email
Attention
parents : Please volunteer and help our league.
Without you the basketball league will not exist.
Please sign up for the following positions to help the league.
Please indicate how you can help
support the program this year
(Check all that apply)
Head
Coach
Assistant
Coach
Game
Day Manager
Hall
Monitor
Volunteer
Committee
Fundraising Committee
Scorekeeper
Electronic
Scoreboard
School
Security
Emergency Medical Information/Consent for Treatment
I do give
consent for treatment of the child named above in any case of my
unavailability, should any emergency need, medical or surgical,
arise for my child during the season. Should a specialist’s advise
or services be required, please list preference:
Emergency Contact
Emergency Contact Home Phone
Emergency Contact Cell Phone
Hospital/Emergency
Facility Preference
Family Doctor
Doctor Phone
Health Insurance
Company Name
Policy #
Group #
Tetanus Injection --
Participant 1
(date -- mm-dd-yy)
Enter "00/00" if unknown
Tetanus Injection --
Participant 2
(date -- mm-dd-yy)
Enter "00/00" if unknown
Tetanus Injection --
Participant 3
(date -- mm-dd-yy)
Enter "00/00" if unknown
Please list
allergies, especially to any food, fluid, bee stings or medicines
[Identify allergies by
participant]
List Medical Conditions
we should be aware of
[Identify medical
conditions by participant]
Does your child wear
contacts?
Yes
No
If YES, which child(ren)?
List medications your
child is currently taking
[Identify medications by
participant]
This form is shown for information
only.
The form CANNOT BE SUBMITTED.
Consent and Waiver
By my electronic signature and submitting this form, I, the parent
or guardian of the child(ren) named above, hereby give my approval
for his/her/their participation in any and all the activities
required during the current basketball season. I assume all the
risks and hazards incidental to the conduct of the activity, as well
as transportation to and from such activities. I hereby release,
absolve, indemnify and hold harmless PAXTON ATHLETIC ASSOCIATION
(the association), the organizers, sponsors, coaches, supervisors,
and/or any other persons placed in a supervisory capacity over such
activities, and hereby waive any claims which may arise because of
this agreement and/or activities.
I hereby attest that I carry insurance and fully
agree that any injuries incurred by the player(s) during these
activities will be charged to this insurance. I understand that the
Association carries an excess insurance policy which will, within
the limits of such policy, pay any medical, dental, and/or hospital
expenses not paid by my insurance, providing such injury is reported
to the association within forty-eight hours (48) of such injury.
I understand that there will be additional
equipment required by the player(s) that is not furnished by the
association. Sneakers, socks, gym shorts are some of the items that
may be required and they will be my responsibility.
To all the above I formally agree and give my full
consent and approval to this/these player(s) entering the basketball
program.
Photo Release for Children
Under 18 Years of Age
I hereby grant Paxton Athletic Association to use the
photo and or other digital reproduction of his/her physical likeness
for publication processes, whether electronic, print, digital or
electronic publishing via the Internet.
Paxton Basketball
Spectator/Player Code of Conduct Policy
The Paxton Athletic Association Board of Directors
and the Paxton Basketball League has adopted the following conduct
policy towards spectators, coaches, league officials and players.
I. The following WILL NOT BE TOLERATED DURING
Paxton A.A. BASKETBALL EVENTS or on Central Dauphin School District
property.
Unsportsmanlike behavior from any staff member,
coaches, players, parents, family members and spectators during
Paxton Basketball practices, games, and Events on Central
Dauphin School District Property or other venues were Paxton
Basketball teams participate in.
Any inappropriate behavior that is considered
detrimental to our children, participants, or this organization
and its members during basketball functions or on Central
Dauphin School District Property.
Fighting or other violent behavior from any person
involved in any activity of Paxton Basketball or on Central
Dauphin School District Property.
Spectators interference with officials of the
on-going game which may not set a good example for players. This
may include harassment, verbal language, and conversation
related to game while game is in progress with the official.
Officials include coaches, scorekeepers and PIAA referees.
Spectators interference with league officials
during any game will not be tolerated. This includes before,
during and after any league game during any point of the season
and post-season tournament. Interference includes verbal,
physical, and another other kind of abusive view expressed by
the spectator.
Failure to follow all rules of said basketball program
related to code of conduct.
II. The Paxton Athletic Association reserves the right to
ask any person to remove themselves from a Paxton A.A. basketball
event if Basketball commissioner and/or league coordinator involved
in the current game all agree that the action warrants it.
At no time will a member of the Paxton A.A.
basketball program enter into a physical altercation trying to
remove a person(s) from any basketball event.
Once a person(s) has been asked to leave a Paxton
Basketball event they may not return to a Paxton Basketball
venue until the Paxton A.A. Board of Directors has agreed to
allow that the person(s) back into Paxton Basketball functions.
This will be at the next regular scheduled Paxton A.A. board of
directors meeting where all parties can state their case of
reservations. (1st Thursday of every month)
Any person will be held liable for damage of fines
incurred during an event such as fines levied by PIAA referees,
CDSD and/or the Paxton Athletic Association.
PAXTON ATHLETIC ASSOCIATION FUNDRAISING POLICY
FOR 2011-2012
The Paxton Athletic Association requires each player
in the association’s basketball program to sell fifteen (15) items in
the designated fundraiser. Failure to sell ten items will prevent
the player from playing in the post season playoffs, being
considered for post season all-stars, and receiving participation
awards or trophies which may be awarded to other team members who
sold at least ten items.
This season the association will permit a buy out from the
fundraiser for $60 per player over the registration cost. This
amount is to be paid at registration.
The association does not permit players to wait until they see
whether they would make an all-star team or otherwise be eligible
for trophies to decide to sell ten items or buy out.
This policy is mandated by the board of directors and cannot be
changed by the commissioner or any coach.
This form is shown for information
only.
The form CANNOT BE SUBMITTED.
Type
of payment to be submitted
Secure payment
form is at bottom of this page,
and must be submitted separately
after completing this Registration Form.
--------------- Please select ONE ---------------
Individual Registration -- $52.00 (No Buyout)
Individual Registration + Buyout -- $112.00
2-Child Registration -- $89.00 (No Buyout)
2-Child Registration + 1 Buyout -- $147
2-Child Registration + 2 Buyouts -- $209.00
3-Child Registration -- $126.00 (No Buyout)
3-Child Registration + Buyout -- $306.00
No payment -- Family Payment made previously.
We will pay by CHECK at the Registration event
PLEASE NOTE
that if you chosse the FUNDRAISER option you must contact Joe Acri
during the month of September to receive your fundraiser
information.
Joe may be contacted at basketballcommissioner@paxtonathletics.org.
Parent or Guardian
Electronically Signing Form
Today's Date
mm-dd-yy