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2. Today's Date*
   Today's Date
4. Participant Name*
5. Middle Initial
6. Last Name*
8. Current Address: Street*
9. City*
10. State*
11. Zip code*
13. Phone Number*
14. Work Phone
15. Email Address*
17. Gender*
    -- Select One --MaleFemalePrefer Not to Say
18. Age today*
    -- Select One --67891011121314
19. Child's Date of Birth*
21. Grade level*
    -- Select One --Kindergarten1st grade2nd grade3rd grade4th grade5th grade6th grade7th grade8th grade
22. Shirt size *
    -- Select One --Youth small Youth mediumYouth large Adult small Adult medium Adult largeAdult X-large Adult XX-large
23. Are you interested in being a coach?*

    1. Yes, I am interested in being a coach.
    2. No, I am not interested.
25. Additional Child(ren)
26. Age today
    -- Select One --567891011121314
27. Gender
    -- Select One --MaleFemalePrefer Not to Say
29. Child's Date of Birth
30. Shirt size
    -- Select One --youth smallyouth mediumyouth largeadult smalladult mediumadult largeadult x-largeadult xx-large
31. Grade level additional child
    -- Select One --Kindergarten1st grade2nd grade 3rd grade4th grade5th grade6th grade7th grade8th grade
33. Parent/Guardian Name*
34. May also be released to: *

    Must be at least 18 years old

36. Allergies/Health Problems, past or present*
38. Emergency contact Name*
39. Emergency Contact number*
41. Activity*
    -- Select One --PEE WEE BASKETBALL (K-5th grade)Middle school basketball (6-8th)

    Tuesday and Thursday at a local elementary school to be identified during informational meeting. 

    Additional information

    The registration fee for the first child is $90.00 and any additional child is $75.00 

    The Romulus Recreation Department has been relocated to the Romulus Athletic Center 35765 Northline Rd. Please call (734) 941-8665 for more information. 

43. Waiver, Release of Liability & Indemnity Agreement

    In consideration of my or my child’s acceptance of my or my child’s registration in the above program(s) do I hereby, for myself or my child, my heirs, executors and administrators, waive release and forever discharge any and all rights and claims for damages which I or my child may have or which hereafter accrue to me or my child against all municipalities special districts, and properties through which the program(s) will be held or its respective officers, instructors, administrators, successors, and/or assigns for any and all damages which may be sustained or suffered by me or my child in connection with my said participation in the above program(s). I further represent that I or my child are in good physical condition and have no disability or ailment that will prevent me or my child from engaging in the activity for which I am registered.

    Our Photo Policy: Enrollment in Parks and Recreation Department sponsored programs authorize Romulus Parks and Recreation, its departments, employees and contractors to take your or your child’s photograph for use in future brochures, flyers, documents, displays, and other publications, website and on social networking websites. Parks and Recreation will not sell, use or authorize others to use such photographs for commercial purposes.

    I, the undersigned parent or legal guardian of the child shown below, have read the above Waiver, Release and Indemnity Agreement and agree to its terms on behalf of my child and myself.  I understand that by signing below, I am giving up substantial rights on behalf of my child and myself.

45. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
47. Electronic Signature*
49. Disclaimer

    No class/program confirmations are mailed out. You will only be notified if your class/program is cancelled. Proper fees must be enclosed for valid registration. No class or program openings will be held or saved for persons registering without payment. Registrations are taken on a first come, first serve basis. Mail-in registrations must be received at least one (1) week prior to the beginning of class. Check or money order is accepted. Nominal fee will be charged for credit card use. Checks can be made out to the City of Romulus.

51. Please Pay Here
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