Essex Fells, Fairfield, North Caldwell & Roseland Recreation Departments

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 [e-mail]

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 21^st

REGISTRATION BEGINNING NOW:

<sup>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