Roseland Recreation Department
140 Eagle Rock Avenue
973/403-6822 or
Mayor John Duthie
2015/16 WINTER YOUTH BASKETBALL
A/WEST ESSEX SENIOR BOYS & GIRLS LEAGUES (GRADES 7 - 8)
B/WEST ESSEX JUNIOR BOYS & GIRLS LEAGUES (GRADES 5 - 6)
C/WEST ESSEX NEIGHBORHOOD BOYS & GIRLS LEAGUES (GRADES 3-4)
Projected Start: Practice (Grades 3-8 -Boys and Girls-week of 11/30/15) and Games (all levels) week of 1/4/16
Mail or walk into - Roseland Recreation Department 140 Eagle Rock Avenue, Roseland, NJ 07068
Recreation Office hours are Monday through Friday from 8:30 a.m. - 4:30 p.m.
FEE: $125.00 Make checks payable to: Borough of Roseland Deadline: Friday, November 6th
Important - all participants registering after the deadline will be assessed a $15.00 late fee.
UNIFORM RETURN POLICY: Please be advised that failure to return the full uniform to your coach within two weeks of the close of the season will result in a suspension from all recreation privileges. If the uniform is damaged or lost, there will be a $30.00 replacement fee.
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DETACH HERE DO NOT WRITE BELOW!
PLEASE NOTE: ONE FORM PER PARTICIPANT ______
CASH CHECK # AMOUNT DATE REC’D.
2015/16 WINTER YOUTH BASKETBALL
NAME______
ADDRESS______/______/______/ ______
STREET/PO BOX TOWN STATE ZIP
HOME ______MOM CELL______DAD CELL______
E- MAIL ADDRESS______
AGE ______GRADE ______SEX ______HEIGHT ______(Please be accurate!)
Did your child play last year? Yes____ No____ League Last Year? ______Does your child play another winter sport? Yes ___ No ___
Does your son/daughter have any health condition(s) the Recreation Department Staff should know about? No _____ Yes _____ Explain:______
Child Photo / Video / Release Form
I grant permission for the Borough of Roseland, Roseland, New Jersey to use photograph(s)/moving image(s) of my child participating in Borough programs and/or activities for promotional purposes. I understand that photographs or recordings may be utilized by the Borough at its discretion for materials including, but not limited to: newsletters, brochures, television, video tape and flyers. Photographs sent to the local
newspaper may have names noted. There will be no valuable consideration paid as a result of this activity. Yes ___ No ___
PARTICIPANT WAIVER OF CLAIM FORM: As partial consideration for the Borough of Roseland providing ______(“Participant”) with the opportunity to participate in Basketball I, ______, as parent or guardian of Participant, on his or her behalf and on my own behalf and that of my spouse or partner, agree to hereby 1) acknowledge that there are foreseeable and unknown risks inherent in participation in the Program, 2) release, indemnify and hold harmless the Borough of Roseland, it officials, departments, employees, volunteers, contractors, insurers, including the NJIIF and the Borough of Roseland, its owners, employees, volunteers and subcontractors from and against all claims, losses, costs an damages arising from Participant participation in the Program, and 3) agree that for any loss or damage suffered by Participant will be turned over to parent / guardian’s insurance company. I also represent that the Participant has been cleared by his/her physician to participate in the Program. If a medical emergency should arise and the parent / guardian cannot be reached immediately at the home phone # (______), at the work phone # (______), at the emergency phone # (______) or via the cell phone # (______), I, parent or guardian, hereby grant medical personnel to take whatever means he or she deems necessary to safeguard the welfare of the Participant.
Print Name ______Signature______Date______
please NOTE: The Recreation Department will not honor requests to be placed on a specific team.
PARENTAL ASSISTANCE: I am interested in:
Head Coach______Assist. Coach ______NAME______
Sponsorship of Team______
HOME PHONE ______WORK PHONE ______
CELL PHONE: ______E-MAIL ADDRESS: ______
For more program information turn to Comcast Channel 35 or Verizon Channel 46, check our website @ WWW.ROSELANDNJ.ORG,
or look in The Progress Newspaper