Essex Fells, Fairfield, North Caldwell & Roseland Recreation Departments
2015 WINTER YOUTH BOYS INTRAMURAL BASKETBALL LEAGUE
WEST ESSEX AREA RESIDENTS (Essex Fells, Fairfield, North Caldwell and Roseland)
973/403-6822 or
Who: Boys and Girls grades 9-12
Where: West Essex Middle School, North Caldwell, NJ 07006
When: League play begins on Friday, December 5, 2014
Games are played on Fridays from 7:00 p.m. - 10:00 p.m.
Fee: $115.00 per person, due by Friday, November 21st
REGISTRATION BEGINNING NOW:
Make checks payable to: Borough of Roseland
Mail Registration to: Roseland Recreation Dept. 140 Eagle Rock Avenue, Roseland, NJ 07068
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DETACH HERE DO NOT WRITE BELOW!
PLEASE NOTE: ONE FORM PER PARTICIPANT ______
CASH CHECK # AMOUNT DATE REC’D.
2015 WINTER INTRAMURAL BASKETBALL LEAGUE
ARE YOU ALREADY ON A TEAM? ______IF YES, WHO IS THE TEAM CAPTAIN: NAME ______
NAME______
ADDRESS______/______/______/______
STREET/PO BOX TOWN STATE ZIP
HOME PHONE______EMERGENCY PHONE______
E- MAIL ADDRESS______CELL PHONE ______
AGE ______GRADE ______Did your child play last year? Yes____ No____
Does your son/daughter have any health condition(s) the Recreation Department Staff should know about? No _____ Yes _____ Explain:______
THE ESSEX FELLS, FAIRFIELD, NORTH CALDWELL AND ROSELAND RECREATION DEPARTMENTS RECOMMEND THE DISCLOSURE OF RELEVANT HEALTH INFORMATION. UNLESS THE ROSELAND RECREATION DEPARTMENT IS NOTIFIED IN WRITING, STAFF WILL BE FORWARDED ALL INFORMATION ON THE REGISTRATION FORM, INCLUDING HEALTH CONDITIONS.
Child Photo / Video / Release Form
I grant permission for the Essex Fells, Fairfield, North Caldwell and Roseland Recreation Departments to use photograph(s)/moving image(s) of my child participating in the Intramural Program and/or activities for promotional purposes. I understand that photographs or recordings may be utilized by Essex Fells, Fairfield, North Caldwell and Roseland Recreation Departments at their 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 ___
PARENTS/ADULT SIGNATURE ALLOWING PARTICIPATION AND WAIVES CLAIMS THAT MAY RESULT FROM INJURY DUE TO INTRAMURAL BASKETBALL ACTIVITY.
______SIGNATURE (PARENT/GUARDIAN) DATE
PARENTAL ASSISTANCE: Note: To be an adult (18 years and out of high school) coach you must be certified through either the NYSCA or Rutgers Programs and have completed a background check through the State Police (Identogo) Program.
I am interested in: COACHING ______NAME ______HOME PHONE ______BUSINESS 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