• Parent 1 /Guardian Contact Information (Required)

  *First Name
  *Last Name
  *Street Address
  *City
  *State
  *Zip Code
  *Home Phone
  Work Phone
  Cell Phone
  *E-mail 1
  E-mail 2

• Parent 2 / Guardian Contact Information (Optional)

  First Name
  Last Name
  Home Phone
  Work Phone
  Cell Phone
  E-mail

•  Child Name (Required)

  *First Name
  *Last Name
  *Grade #	Choose.. K 1 2 3 4 5 6
  *Sex	Choose.. Male Female
  *Shirt Size	Please choose.. Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult XL Adult XXL
  *Dues	Choose.. $119 $145 ($119 for K-2 and $145 3-6)
  Volunteer?	Choose.. Team Communications Assistant Coach Pizza Party No
  Allow Photos on the web site?	Choose.. Yes - photos allowed No photos please

   Emergency Contact (Required, if same as above put SAME in both fields)

• Please add any comments, special instructions, health issues we should be aware of  or other information that may be important to us for the 2008-09 Basketball Season!

I certify that I am familiar with the contents of this release and that I accept any and all responsibility for, and assume the risk of any and all injuries to my child, which might arise either directly or indirectly as a result of his or her participation in these programs. I hereby express release, discharge, and hold harmless from any liability whatsoever, Norfolk Youth Basketball, as well as the employees and instructors in their private and individual capacities as they represent Norfolk Youth Basketball and Norfolk Recreation Department, whether salaried, independent contractors or voluntary.

Please type your name agreeing to above statement:

Be sure all information is accurate before submitting the form.

PLEASE ONLY PRESS THE SUBMIT BUTTON ONCE - A CONFIRMATION LETTER WILL APPEAR SHORTLY ON YOUR SCREEN

PLEASE WAIT - IT MAY TAKE UP TO 60 SECONDS FOR THE CONFIRMATION TO APPEAR AFTER YOU PRESS THE BUTTON!