Coach Flem’s
Skills n’ Scrimmage
Basketball practice for 6th to 8th graders
Thursdays, 6-8 pm
Program Description
Open format practice ses-
sions, led by Coach James
Fleming.
Build age-appropriate skills
and sportsmanship through
drills and scrimmage.
Be in tip-top shape for
the Spring Youth Bas- Registration & Rules
ketball Leagues!
Child’s Name_________________________________________
Birthdate: ____________ Age: ____
**Proof of age required. Please photocopy and attach evidence. Acceptable forms of ID are birth certificate, government issued ID
passport, or school ID.
Gender: M F ___ African-American ___ Asian ___ Caucasian ___ Hispanic ___ Other
Guardian #1 Name: ___________________________________ Telephone: _____________ Cell: _____________
Address: ____________________________________________ Zip: _____ Email: _________________________
Relationship: __________________________________
Business Telephone No.: ______________________________ Work Hours: ______________________________
Guardian #2 Name: ___________________________________ Telephone: _____________ Cell: ____________
Relationship: ___________________________________
Address: ____________________________________________ Zip Code: ________ Email: _________________
Business Telephone No.: ______________________________ Work Hours: ______________________________
Emergency Contact: ____________________________________ Telephone No.: _________________________
Address: _____________________________________________ Relationship: ___________________________
Are there any medical conditions we should be aware of:?: _____________________________________________________
_____________________________________________________________________________________________________
I hereby give permission to the Hyde Park Neighborhood Club: (Initial if yes)
____ To arrange for emergency care through a clinic or a hospital in case of illness or accident.
____ I understand by registering for these classes I am releasing the Neighborhood Club from
any liability for injury I may sustain due to my personal carelessness.
_____________________________________________________
Print Name
_____________________________________________________ ____________________
Signature Date