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2021 Hickman Youth Sports Basketball Skills Registration

2021 Hickman Youth Sports Basketball Skills Registration

 K – 3rd Grade

Hickman Parks & Recreation Department
P.O. Box 127, Hickman, NE 68372
www.hickman.ne.gov

 

Participant Name  Date of Birth  Age 

Sex:  M   F    Current Grade in 2021/22 

Parent Name  E-Mail Address 

Address  City  State Zip

Phone Number: Home () Cell () Work ()

    I am Interested in Volunteering   Name:   

***All Checks Payable to City of Hickman***      Registration deadline November 6th

 

$45 includes 6 weeks instruction on Basketball skills and T-shirt.

 

Saturday Morning Dates: Nov. 20th, Dec. 11th ,18th & Jan 1st, 22nd
Dates may change base on availability

From 9:00 am to 11:00 am at the Hickman Community Center

   ***Times/Dates may change as it is based on participant numbers***

 

T-Shirt Size: (Check One)

Youth:  S (6/8)    M (10/12)     L (14/16)

 

Adult:    S       M        L

 Check here if you DO NOT give permission for your minor child/ward(s) picture(s) to be on the City of Hickman Facebook, Website and/or Newsletter.

 

 

WAIVER AND RELEASE OF LIABILITY

 

I have read the Parent/Athlete Concussion Information Sheet

 

Please read this form carefully and be aware that in participating you will be waiving and releasing all claims for injuries that you or your minor child/ward might sustain arising out of this participation.

 

As a participant or parent/guardian of a participant, I recognize and acknowledge that there are certain risks of physical injury and agree to assume the full risk of any injuries, including death, damages or loss which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with this program. 

 

I agree to waive and relinquish all claims I or my minor child/ward may have against the City of Hickman and its officials, officers, agents, servants and employees as a result of participating.  I do hereby fully release and discharge the City of Hickman and its officials, officers, agents, servants, employees and volunteers from any and all claims from injuries, including death, damage or loss which I or my minor child/ward may have or which may incur or may accrue to me or my minor child/ward on account of my participation.

 

I further agree to indemnify and hold harmless and defend the City of Hickman and its officials, officers, agents, servants, employees and volunteers from any and all claims resulting from injuries, including death, damages and losses sustained by me or my minor child/ward and or arising out of connected with, or in any way associated with the activities of my participation.

In accordance with Nebraska Statute 71-9105 (2011), parents and coaches must review the provided items that address the following:

  1. The Signs and Symptoms of a Concussion;
  2. The Risks Posed by Sustaining a Concussion; and,
  3. The Actions an athlete should take in response to sustaining a concussion, including the notification of his or her coaches.
    (More information is available at www.cdc.gov/concussion/HeadsUp/youth.html)

By signing this form I acknowledge that I have read and fully understand the above warning of Risk and Waiver and Release of All Claims and have received information in accordance with Nebraska Statute 71-9105 regarding concussions.

                  

Parent/Guardian Signature (Required)             Date 

 

 

 

 

 

Make Checks Payable to: City of Hickman Parks & Rec.

 

For Office Use Only

Date Received _____________ Fees Paid Total $ ________ Check # __________   Receipt # _____________

 

 

 

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