OLIVER SPRINGS YOUTH CLUB
Basketball Sign-Up
Receipt #_______________
Paid____________
Cash___________
Check#_________
Other___________
To participate in the Oliver Springs Basketball program offered by the Oliver Springs Youth Club.
Furthermore, I hereby relieve OSYC, Dyllis Elementary School and any facility used for games or practices of
all liabilities, including medical expenses, should the above named child incur any injury while participating in,
traveling from, prior to and immediately after any and all scheduled Oliver Springs Youth Club approved
events (games, scrimmages, practice sessions, etc.). I further agree to reimburse OSYC and/or Dyllis
Elementary School or other facility for the replacement cost for any and all items lost, stolen, and/or
otherwise rendered unusable (as determined by the OSYC) that are issued to the child for participation in
this program. I further relieve OSYC and Dyllis Elementary School or other facility of any responsibilities from
the loss and/or theft of any and all personal items.
*When signing this form, you as a parent or guardian will be required to work a ONE HOUR
MINIMUM in the concession stand or at the gate before or after your child's game. We also need
help with clean-ups. Without the concession stand revenues, we will not have adequate funding
to maintain our program. Your child's coach or a concession stand representative will have
sign-up sheets to help you choose a time to fit your schedule.
I, the undersigned, hereby give permission for
____________________________________ ___________________________________
Child's Name Date of Birth (Must be 5 before or on May 1)
SIGNATURE OF PARENT OR GUARDIAN:______________________________________Date:___________
Father's Name (or guardian)__________________________________Email address:__________________
Address:_______________________________________________________________________________
Home Phone:______________________________________Cell Phone:____________________________
Employer:_________________________________________Work Phone:___________________________
Mother's Name (or guardian)__________________________________Email address:__________________
Address (if different):______________________________________________________________________
Home Phone (if different):_____________________________Cell Phone:____________________________
Employer:_________________________________________Work Phone:___________________________
Name, Address, & Phone Number for nearest relative not living with you:______________________________
______________________________________________________________________________________
*IF YOUR CHILD'S UNIFORM IS NOT RETURNED:
1. Your child will not receive a trophy.
2. Your child will not be allowed to participate any more programs offered by the O.S.Y.C.
3. Your child will be responsible for the total cost of a uniform replacement, currently $60.00.
*If you are interested in assisting with a team, then please check here:__________
*Do you have health insurance for your child? Yes_______ No_______