Kingston Impact Basketball Club

One Form Per Player - Personal Information

* are required.

Last Name:*

First Name:*

Birthdate:*

	/		/
YYYY		MM		DD

Gender:*

Male Female

Street:*

Apartment/Unit:

City:*

Postal Code:*

Home Phone:*

Format: 613-555-5555

Email:*

Parent/Guardian 1:*

Alternate Phone:*

Format: 613-555-5555

Parent/Guardian 2:

Alternate Phone:

School:

Programs and Registration Fees

Check all boxes that are applicable for this player.

House League Programs

	Little Guys & Girls West Born 2004-2005 Cost $80 - Late Rate Saturdays 8:00am - 9:00am at Bayridge S.S.
	Novice Boys West Born 2002-2003 Cost $80 - Late Rate Saturdays 9:00am - 10:30am at Bayridge S.S.
	Novice Boys East Born 2002-2003 Cost $80 - Late Rate Sundays 12:00pm - 1:30pm at LaSalle S.S. Note: depending on interest this may be open to boys born in 2001 - please contact admin@kingstonimpact.ca if interested.
	Novice Girls West Born 2001-2003 Cost $80 - Late Rate Saturdays 3:00pm - 4:30pm at Bayridge S.S.
	Novice Girls East Born 2001-2003 Cost $80 - Late Rate Sundays 12:00pm - 1:30pm at LaSalle S.S.
	Atom Boys Born 2000-2001 Cost $80 - Late Rate Saturdays 10:30am - 12:00pm at Bayridge S.S.
	Bantam Boys Born 1998-1999 Cost $80 - Late Rate Saturdays 12:00pm - 1:30pm at Bayridge S.S.
	Bantam Girls Born 1998-2000 Cost $80 - Late Rate Saturdays 1:30pm - 3:00pm at Bayridge S.S.
	Grad Girls Born 1995-1997 Cost $80 - Late Rate Thursdays 6:30pm - 8:00pm/8:00pm - 9:30pm (alternate with boys) at Bayridge S.S. Note: depending on enrollment, the girls/boys grad leagues may merge
	Grad Boys Born 1995-1997 Cost $80 - Late Rate Thursdays 6:30pm - 8:00pm/8:00pm - 9:30pm (alternate with girls) at Bayridge S.S. Note: depending on enrollment, the girls/boys grad leagues may merge

In order to participate in the Kingston Impact Program, you must agree to all of the following legal notices.

REFUND POLICY
It is important to note that applications will be processed on a first-come, first-served basis. The Kingston Impact do not hold spots for anyone & there is no guarantee a spot will be available. In order for the player to be registered, the registration fee must be paid (registration is complete once the bank clears the cheque) and all sections of the registration form completed. Post-dated cheques must be post-dated cheques will not be accepted. A charge of $30 applies to all NSF cheques. All requests for a refund MUST BE MADE IN WRITING by mail or email (info@kingstonimpact.ca) to our Administrator. No administration fees will be applied to withdrawals prior to the first session of the program. An administration fee of $30 applies to all withdrawals between the first session and the second scheduled game. No refunds will be accepted after the second scheduled game has started. Refunds will be issued within 2 weeks of receipt of the written notice.
ACCEPTANCE OF TERMS AND CONDITIONS
I am the parent or guardian of the above named player and hereby authorize the personnel of the Kingston Impact Basketball Club to act for me according to their best judgment in any emergency requiring medical attention. I am also aware of the risks and hazards of playing basketball which could include serious or permanent injury. I hereby waive and release the club, its affiliates, all sponsoring and assisting employees and agents from any and all liability for any injuries incurred while attending the program.
I ACKNOWLEDGE MAKING THIS AGREEMENT
Do you agree that you, , are the parent or legal guardian of the player being registered and to be bound by this "Refund Policy", "Acceptance of Terms and Conditions" even if you have not read the agreements? Yes No