EmailMe Form - HAYC3 2012-2013 Registration Form

Type of Membership *

Individual ($30/year)

Family ($60/year)

Senior/Grandparent ($25/year)

Please list the names (first, MI, last), age, grade and school (if applicable), birthdate, gender, and race* for each individual to be included in membership. *

*this information is collected for grant purposes only.

Parent/Guardian (1) *

First Last

Relationship *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone *

### - ### - ####

Cell Phone

Work Phone

Email *

Parent/Guardian (2) *

First Last

Include address and phone numbers only if different if those listed for previous.

Relationship *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone *

Cell Phone

### - ### - ####

Work Phone

Email *

Phone

Please list any medical conditions, allergies, or special restrictions your child has that staff should be aware of. Please list medications your child takes on a regular basis.

CODE OF CONDUCT:
-Respect HAYC3 staff, equipment, building, and peers
-Only use appropriate language
-No bullying
-Clean up after yourself
-Actively support each other
-Be honest

By signing below, I agree to waive, release, and discharge all rights and claim in respect to damages or injuries sustained by my family, myself, or my child from training, competitive play, non-competitive play, travel to and from activities by organized transportation, and any other recreation activities, or from any other aspect of participation in activities organized by the HAYC3. I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Dentistry or qualified First Aid or CPR technician. This care may be given under whatever conditions are necessary to preserve life, limb, and well-being of those listed on this form.

Adult Signature

First Last

Date

MM / DD / YYYY

Youth Signature

First Last

Date

MM / DD / YYYY

IMPORTANT INFORMATION

Your membership will not be valid until payment is received. You may choose to pay online using PayPal or you may send a check to HAYC3, PO Box 492, Hoosick Falls, NY 12090.