LINDSAY WILDCATS BASKETBALL ASSOCIATION
www.lindsaywildcats.ca
UNDER-18 PLAYER/PARTICIPANT REGISTRATION FORM
PLAYER/PARTICIPANT INFORMATION (please complete ALL areas):
First & Last Names:
Date Of Birth (Month/Day/Year):
/
Home Address (Street Number & Name + Mailing if applicable):
City:
Info (as of December 31 this year):
Age:
Grade:
Gender:
/
Postal Code:
[ ] Female [ ] Male
Home Phone Number:
(
Cell Phone Number (required for Rep): Health Card Number (required for Rep)
)
(
)
Medical Conditions (List all conditions, medications being taken, and indicate if player wears Medic Alert bracelet):
Prior Basketball Experience Level (please record in the box on the left the HIGHEST “LEVEL” of experience over the last 2 calendar years):
“
“
None=“0”
School Team=“1” House League=“2”
Steve Nash=“3”
Summer Camp=“4”
Rep League=“5”
HOUSE LEAGUE ONLY: Is player involved in any activities that may conflict with Thursday’s from 6:00-9:00pm? If “Yes”, provide details:
PARENT/GUARDIAN & EMERGENCY CONTACT INFORMATION (please complete ALL areas):
Primary Email Address of Parent(s)/Guardian(s):
1st Emergency Contact Relationship To Player:
Additional Email Address that you would like LWBA emails to go to:
First & Last Names:
Cell Phone Number:
First & Last Names:
Cell Phone Number:
PARENT/GUARDIAN
(
2nd Emergency Contact Relationship To Player:
(
)
)
PARENTAL ACKNOWLEDGEMENT AND AGREEMENT (please read and sign below):
By signing below, I hereby acknowledge that I agree and consent to the terms of the LWBA’s Limited Liability Policy,
Photographic Imagery Policy, and Administration Fee Policy listed at the bottom of the page:
Parent/Guardian’s Name (please print):
Parent/Guardian’s Signature:
REGISTRATION PROCESS & SUBMISSION OPTIONS (For Both Summer Camp and House League):
1): REGISTER NOW to secure your spot in our program(s); complete in full & deliver/mail/fax your registration form.
Deliver/Mail To: LWBA, Attention: Hugh Shannon, 21 Fair Avenue, Lindsay, Ontario K9V3P2
Deliver To: Scotiabank, Attention: Hugh Shannon, 165 Kent Street West, Lindsay, Ontario
Fax To: (705) 324-2189 Attention: Hugh Shannon (please deliver/mail original as well).
Attend (House In-Person Registration: Thursday September 04, 2014 6:30pm-8:30pm
League only): City of Kawartha Lakes Police Service Building, Victoria Avenue, Lindsay
2): Choose your Registration Pricing Option (make cheques payable to Lindsay Wildcats OBA.).
[] PAY NOW (ie. By the “Early” deadline) and SAVE MONEY by paying the lower fee.
[] PAY LATER (ie. After the “Early” but By the “Regular” deadline) by: 1) including post-dated cheque(s) with your
registration; or 2) delivering/mailing payment at a later date; or 3) bringing payment to the In Person Registration.
SUMMER CAMP
Early
Regular
Jun 07
Jun 30
REGISTRATION DEADLINE & PRICING OPTIONS:
HOUSE LEAGUE
Early
Regular
Jun 07
Sep 04
st
[] Single Player (1 fee increase in over 5 years):
$135
$150
$135
** Family Pricing Discounts (PRICES PER PERSON, MUST BE FROM SAME FAMILY/HOUSEHOLD)**
[] Register 2 Players/Participants From Same Family/Household, PER PERSON:
$120
$135
$120
[] Register 3+ Players/Participants From Same Family/Household, PER PERSON:
$110
$125
$110
- Names of Additional Person(s) Being Registered:
PAYMENT RECORD:
[] Early
SUMMER CAMP
$ Amount Date Paid
Registrar
[] Early
HOUSE LEAGUE
$ Amount Date Paid
$150
$135
$125
Registrar
[] Regular
[] Regular
Record Type, Amount & Date:
[] JUMPSTART FUNDING: Check this box if you have/will be applying for Jumpstart funding for this person.
Liability of the LWBA and/or any of its officials, affiliates or sponsors, does not extend to any form of injury, damage or loss resulting from any accident,
from known or unknown conditions, handicap, or infection caused while participating in or traveling to or from any LWBA activity. Photographic Images
taken of LWBA participants during games, practices or in the promotion of the LWBA, may be used at the sole discretion of the LWBA, along with the
use of the participant’s name. Administration Fee of $25 will be charged for any/all of the following: a) NSF cheque(s); b) Late Registration (received
after the Registration Deadline); c) Refunds requested after the Season Start Date (issued at the sole discretion of the LWBA).