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MEMBER CERTIFICATION FORM
PAYMENT & FORM DUE ON OR BEFORE 9/10/15 / Complete all items & send along with $350 Annual Council Dues to:FCYBL
c/o E J Thomas1609 Montmorency Dr.
Vienna, VA 22182
In order to participate as an active member of the Fairfax County Youth Basketball Council and to field teams in the Fairfax County Youth Basketball League, all organizations are required to complete and return this form along with annual dues fee payment in the amount of $350. Please read this form carefully and complete ALL items. Any club whose form is returned late or incomplete may be excluded from participation in the FCYBC and FCYBL.
FCYBL RULES:
As the official FCYBC Representative for my club, I acknowledge that it is my responsibility to provide timely delivery, accurate interpretation, communication, and enforcement of all of the FCYBL rules and charter information to all of the coaches and parents affiliated with my organization who participate in the FCYBL. I understand that any issues or questions concerning either the FCYBL rules or the FCYBC charter should be addressed immediately and prior to the signing of this disclosure form/document.
FCYBL PLAYER COUNT:
The FCYBL Rules require each member organization (youth club, recreation center, etc.) to provide the FCYBC with an official player count based upon actual “county” and “house” totals from the previous year. Please complete the table below based upon the following criteria:
· By using the player count from last season (2014-2015), indicate the number of players within your program as one year older. For example, if your club had 88 boys who were in the 6th grade last year, you should indicate 88 boys in the 7th grade category for this year’s form.
· Your totals should include all players in your organization- this includes both county and house league players combined!
· Even if your club did not (last year) or may not (this year) enter a county team in every age group, you are required to complete all categories on this form.
· There should be no blank boxes on this form. If your club has or had no players in any of the age/gender brackets, indicate as “0”.
# PLAYERS / 5th Grade / 6th Grade / 7th Grade / 8th Grade / 15 & Under / 18 & Under# GIRLS / *Include w/18’s
# BOYS
CONTACT INFORMATION & CONFIRMATION:
As officials of , we certify that the information listed on this form is complete, correct, and has been read and understood by all who sign below. By signing below, we agree to abide by all FCYBC/FCYBL rules and guidelines as stated. For the purposes of verification and to update the FCYBC records, the appropriate responsible officers have completed this form and have signed individually for only themselves.