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5th and 6th Grade Basketball 2025 Online Registration - Sign-up Deadline: August 22nd
REGISTRANT INFORMATION
*
First Name:
*
Last Name:
*
Date of Birth:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2012
2013
2014
2015
*
2025-2026 Grade:
Fifth Grade
Sixth Grade
*
Gender:
Female
Male
Home Phone/Land Line (999-999-9999):
*
Address:
*
City:
*
ZIP Code:
*
Shirt Size:
Youth - Small
Youth - Medium
Youth - Large
Youth - X-Large
Adult - Small
Adult - Medium
Adult - Large
Adult - X-Large
This registrant has a sibling in the same division.
If the box above is checked, name of sibling in the same division:
PARENT/GUARDIAN INFORMATION
*
Relationship to Registrant - Parent/Guardian 1:
Mother
Father
Stepmother
Stepfather
Grandmother
Grandfather
Other
*
First Name - Parent/Guardian 1:
*
Last Name - Parent/Guardian 1:
*
Mobile Phone (999-999-9999) - Parent/Guardian 1:
*
E-mail Address - Parent/Guardian 1:
Will Be A Coach - Parent/Guardian 1
Relationship to Registrant - Parent/Guardian 2:
Mother
Father
Stepmother
Stepfather
Grandmother
Grandfather
Other
First Name - Parent/Guardian 2:
Last Name - Parent/Guardian 2:
Mobile Phone (999-999-9999) - Parent/Guardian 2:
E-mail Address - Parent/Guardian 2:
Will Be A Coach - Parent/Guardian 2
Comments:
As a participant in this program, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, including loss of life, damage or loss which my child may sustain as a result of participating in this activity. I further agree to waive and relinquish all claims, fully release and discharge and agree to indemnify and hold harmless and defend the park district and their officers, agents, servants, and employees from any and all claims resulting from injuries, including loss of life, damages, and losses.
I AGREE TO THE STATEMENT ABOVE
*
Please note: If teams have been set up and are full, a late registration will not be accepted.
* indicates required fields
SELECT FEE
$55.00 - I live in the Teutopolis Park District and pay Teutopolis Park District taxes.
$75.00 - I do not live in the Teutopolis Park District.
