HEALTHY CONFIDENT CONNECTED - YMCA of Central Ohio

HEALTHY
CONFIDENT
CONNECTED

TEEN BASKETBALL LEAGUE

LIBERTY TWP/POWELL YMCA

Our focus on youth development provides an environment
that will help each child and teen develop relationships,
improve self-esteem, and build character. You will find our
staff and volunteers focus on teaching the fundamentals and
ensuring that everyone plays.

REGISTRATION: November 1st – December 6th CONTACT
LATE REGISTRATION: December 7th - 11th
Zach Lucas
$10 Late Fee Sports and Camp Director

FEES: Liberty Twp/Powell YMCA
7798 North Liberty Road
Tier 1 Family Membership: $75.00 Powell, Ohio 43065

Tier 2 Youth Membership: $95.00 614 839 9622
[email protected]
Tier 3 Non-Member: $105.00

PRACTICES: Begin the week of December 28th

GAMES: Start Saturday January 9th

Last Game February 13th

BECOME A COACH! Coach Meeting Wednesday December 16th 7:30-8:00 pm

Help our community be healthy, gain confidence and stay connected. Find YOUR application at our
member services desk. All volunteers are subject to a background and reference checks.

** Tier I Family membership Tier II Youth membership Tier III Non member

ymcacolumbus.org/liberty

YMCA TEEN BASKETBALL REGISTRATION – Winter 2016

Participant’s Name____________________ Phone (____) ________________

Address___________________________ City_____________ Zip Code______

Gender (Circle 1): Male/Female Age_____ Grade______ Height_______

Jersey Size: Adult S, M, L, XL School Attending:________________________

Email Address__________________________ D.O.B______________

Fee: Tier 1: $75.00 Tier 2: $95.00 Tier 3: $105.00

Jersey Fee $15

I do hereby stipulate and agree to indemnify and hold forever harmless the YMCA of Central
Ohio against any and all claims arising from my own or my child’s participation in the YMCA
programs or activities.

Parent Signature_______________ Print Name________________ Date_____

I wish to volunteer for: (Please check one if interested)
_____ Coach: I am willing to volunteer as a coach with YMCA sports program while reinforcing
the character development values of CARING HONESTY, RESPECT AND RESPONSIBILITY.
Coaches are required to fill out a volunteer application and attend a coaches meeting.

Coach’s Name____________________Phone Number (___)_______________

Email Address__________________________ Shirt Size____

Requests
Player 1__________________________________
Player 2 __________________________________
Player 3 __________________________________
Player 4 ___________________________________

Coach Request ______________________________

YMCA of Central Ohio Youth Sports Program Participation

CONCUSSIONS
I have been given a copy of the Ohio Department of Health Concussion Information Sheet for Youth
Sports Organizations. I acknowledge that if a concussion is suspected, then the program participant will be
required to provide WRITTEN clearance from a health care provider, as defined in the statute, prior to
returning to participate in any YMCA activities.

HOLD HARMLESS
In consideration for being allowed to participate in YMCA membership and programs, I agree to assume
the risk of such activities and further hold harmless the YMCA, employees and volunteers from any and all
claims, suits, losses, or related causes of action for damages, including, but not limited to, such claims
that may result from my injury or death, accidental or otherwise, during or arising in any way from my
YMCA involvement.

PHOTO RELEASE
Membership cards will be issued and each member’s photo will be taken and held in the YMCA’s
membership software program for identification purposes. Additionally, in consideration for being allowed
to participate in YMCA membership and programs, I understand that images, video and film footage is
often used by the YMCA of Central Ohio for promotional purposes. For my participation in activities to be
conducted by YMCA of Central Ohio I hereby give my permission and consent, now and for all time, to
YMCA of Central Ohio, the National Council of Young Men’s Christian Associations of the United States of
America (YMCA of the USA) and third parties collaborating with YMCA of Central Ohio to make, reproduce,
edit, broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of
me and/or my narrative account of my experience at YMCA of Central Ohio, for publication, display, or
exhibition thereof in promotions, advertising and legitimate business uses without any compensation to,
and/or claim, by me. I may, or may not be, identified in such reproductions; however, I shall not be
stated by name to have endorsed any particular commercial products or commercial services.

I have read and agree to the terms, conditions, and statements listed above.

YMCA of Central Ohio Branch___________________ Sport/Activity______________________

Participant Name (Print)______________________________Date______________________

Parent Name (If Under 18)______________________________________________________

Signature (Parent if under 18) __________________________________________________