435 N. Wisconsin Drive Howards Grove, WI 53083

phone: 920-782-0207 web: http://hgactivitycenter.weebly.com

Registration Form: Little Ballers Basketball Ages 4 – 6 Cost of Program: $35 (Make checks payable to Howards Grove Activity Center) You may mail forms, or call to schedule a drop off time Registration Due Date: Tuesday, January 23 rd (If class has limited spots mailing registration doesn’t guarantee spot) Return lower portion of this form with your payment.

Instructor – Matthew Trumm Class held from 5:30 – 6:15 pm on the following Thursday’s: January 25th, February 1st, 15th, 22nd. No class Thursday, February 8th A parent is required to be present during the class. Your child will learn the beginning fundamentals of basketball while practicing team work. The Little Ballers coaching staff will offer a supportive and positive environment for young players to learn all basic basketball skills, rules of the game and most importantly learn how to be on a team and have fun playing our favorite sport! Boys and girls are welcome to participate. Your child will receive a t-shirt for participation. Please enter the doors off the south deck.

------------------------------------------------------------------------------------------------------------------Program Name: Little Ballers Basketball Ages 4 – 6 Cost of Program: $35 (Make checks payable to Howards Grove Activity Center)

First Name:__________________________ Last Name: _________________________________ Date of Birth: ____/____/____ Age: __________ T – Shirt Size: 3T 4T 5/6 7 6/8 10/12

Parent(s):_____________________________________________________________________________ Address: ____________________________________________Home Phone #: ____________________ Email: ______________________________________________ Would you like our e-newsletters? Y N Mother’s Cell#: __________________________Father’s Cell Phone#:____________________________

**Would you be willing to help coach? This would consist of being at practice about 10 minutes early and late, and lead groups in drills, and more. Please write your name in the space below where you would be most helpful. Thank you for considering. Assistant Coach _____Contact phone & email: ________________________________________

Does your child have any medical conditions we should know about? Please indicate condition and/or medication needs._________________________________________________________________________________________________ Physician’s Name: ______________________________________ Phone#:___________________________

Would you give the HG Activity Center permission to use photos of your child in educational or promotional materials? (There is no cost.) Yes: _____ No: ______

In consideration of being able to participate in any way with Howards Grove Activity Center, related events, or activities the participant/guardian must read and sign.

Participant/guardian releases, waives, or discharges any right to take legal action against Howards Grove Activity Center or Hiebing Inc., volunteers, staff, sponsors, advertiser, and lessor premises used to conduct the class, or event. This includes any and all liability to participant that causes injury, death, and or damage to property. We are not responsible for lost or stolen items. You as the guardian releases any rights to seek damages, or replacement cost.

Signature: ________________________________ Date: _________

Office use only:

Paid: ______________ Cash: _____ Check #:__________