NAME	___________________________________________________
ADDRESS	___________________________________________________
PHONE	______________________  MALE_______FEMALE__________
BIRTH DATE	________________________________	GRADE	_________
E-MAIL ADDRESS	________________________________ (PLEASE print clearly)

As parent, guardian, or responsible person for the applicant, I authorize membership in the North Reading Youth Basketball program. I also understand that the coaches, assistants, association officers, or any persons connected with the program are freed from any and all liability while the applicant is engaged in basketball activity or other purposes of this program. I recognize that the program carries limited insurance and it is the responsibility of each individual for any coverage.

___________________________________________________		_________________
SIGNATURE OF PARENT/GUARDIAN		DATE

REGISTRATION FEES:   A fee of $65 is required for each 2nd grade applicant. The town user fee is included in this amount. A fee of $85 is required for each older applicant. The school user fee is included in this amount. An additional $85 is required for any applicant accepted on a traveling team The maximum fee per family is $275. For families only involved in the in-town program, the maximum fee is $185. A late fee of $10 per applicant will be assessed. Children born prior to 1/1/2003 are eligible for the 2nd grade program.   Please make checks payable to N.R.Y.B.

 

CHECK IF YOU ARE ABLE TO COACH _________ PLEASE MAIL THIS FORM AND CHECK (payable to NRYB) TO: Larry Dysart 40 Anthony Road North Reading, MA 01864