REGISTRATION FORM

Grants & Milan Recreation, Grants Recreation 285-3542 Ext 119

****PLEASE READ FORM THOROUGHLY AND FILL IN ALL THE BLANKS****

CHILDS NAME:________________________________________________________________________________                     (Please Print)                                                                                          

 PARENTS NAME:_______________________________________________________________________________                 Please Print)

 PHONE #: (Home)______________________(Cell)_____________________ (Other)_________________________

 ADDRESS: _______________________________________CITY: ______________________ZIP CODE:________

 AGE: ________GRADE:________SCHOOL:__________________ DATE OF BIRTH: _____________________

 DOCTOR: _____________________________INSURANCE:____________________________________________

First Year Participating?          YES        NO      (Circle One)

Team in which child participated in last year? ________________________________

 Female: _______       Male: ________

CO-ED GROUPS                                                                                                                        ALL GIRL GROUPS

Grade Group:                                                                                                                                Grade Group:                                        1^st & 2^nd  ________             3^rd & 4^th ________                                                                          1^st-2^nd-3^rd _________

5^th & 6^th  ________                 7^th & 8^th ________                                                                       4^th-5^th-6^th _________

Home School:         YES   NO               (Birth Certificate Required for Home School Children)                                                                                                  (Circle One)

Father agrees to help:  Coach______   Asst. Coach_______                                                                                                                          Mother agrees to help: Coach______   Asst. Coach_______

Please list any special health factors which your child has, such has Asthma, Heart Conditions, Epilepsy, Diabetes, Allergic reaction to medications, Etc. _______________________________________________________________________________

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WAIVER FOR PARTICIPANT BY PARENT

In consideration of acceptance of this contract and permission to participate in Basketball for the current year of 2006-2007. I hereby, for myself, my heirs, executors, and administrators waive and release any and all rights and claims for damages I may have against the recreation program, Grants/Milan Recreation Department, NMSU, Grants Cibola County Schools and all member associations for any and all injuries suffered in any recreation programs or practice. Upon signing this registration form I also agree to all rules of the Grants/Milan Recreation Departments. I also agree to return all uniforms and equipment issued by the Recreation Departments or team coaches.

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PARENT OR GUARDIAN SIGNATURE                                                                           DATE