Putnam Basketball AAU Tryouts
These forms must be completed before your child can participate in the camp.
Player's Information
Name
*
Address
*
Street Address
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Nickname
Date of Birth:
*
-
Month
-
Day
Year
Date
Grade
*
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Other
School District Player Attends
Please Select
Putnam School District
Pomfret Community School
Woodstock School District
Thompson School District
Killingly School District
Plainfield School District
Brooklyn School District
Dudley / Charlton School District
Webster School District
Oxford School District
T-Shirt Size
YS
YM
YL
AS
AM
AL
AXL
AXXL
Shorts Size
Please Select
YS
YM
YL
AS
AM
AL
AXL
AXXL
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Parents' Information
Parent/Guardian 1
Parent/Guardian 1
*
First Name
Last Name
Relationship to Child
*
E-mail
*
Cell Phone
*
Home Phone
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would you like to be reached incase of an emergency?
*
Cell Phone
Work Phone
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Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Secondary Phone Number
*
Relationship to Child
*
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Medical
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
*
Food
Medication
Environmental
Please list and explain any allergies
*
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
*
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
*
0/150
Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?
*
Yes
No
Please explain
*
0/150
If yes, does this medication, food supplement, or medical food need to be administered at the day camp?
*
Yes
No
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
*
0/150
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Payment and Statement of Understanding
The Putnam Science Clinic/AAU Coaching Staff has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
*
Type first and last name above to consent
This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child receiving care. After the child is attending the program the administrator shall have the parent/guardian review and initial the form when any changes/updates are made and at least annually. The parent/ guardian and the administrator or designee shall initial and date the form in the section below to indicate when the form was last reviewed.
*
Type first and last name above to consent
Sign Document
*
Date Signed
*
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Month
-
Day
Year
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