Nov 1, 2016 - Tryouts: 12/12-12/14 Regular registration: $345 (deadline 12/2). Late registration: $385 (12/3-12/12) ...
Welcome to Walnut Creek Intermediate’s After School Sports Program! Our policy is to offer full participation, as often as possible, provided the student/athlete: maintains a minimum 2.0 grade point average, attends regular practices, maintains a positive attitude, stays focused on the activity, does not distract others by playing around, and is respectful to coaches, students, the facility, equipment and staff. Practices are held at WCI. Games will be played at WCI as well as other Middle Schools throughout the East Bay and Contra Costa County. A City of Walnut Creek Recreation Division employee will supervise all practices and games at our gym. Sport
Grade
Beach Volleyball Coed 34152 Intramural 6, 7, 8
Season Begins
Total Fee (includes a $3.00 processing fee)
November 1, 2016
$265.00
This 6 week program will cover fundamentals of beach volleyball—ideal for individuals looking to learn the intricacies of beach volleyball, improve their indoor game, and/or looking for a new challenge. Practices will be Tuesdays and Thursdays at the Heather Farm Park Sand Volleyball Courts 3:30-5pm (courts are next to Clarke Swim Center). Boys Basketball 33557 Competitive 7*
Tryouts: 12/12-12/14
Regular registration: $345 (deadline 12/2) Late registration: $385 (12/3-12/12) (inc. $70.00 refundable uniform deposit)**
33558 Competitive 8*
Tryouts: 12/12-12/14
Regular registration: $345 (deadline 12/2) Late registration: $385 (12/3-12/12) (inc. $70.00 refundable uniform deposit)**
33549 Intramural
January 2017
Regular registration: $210 (deadline 1/6) Late registration: $250 (1/7-1/17)
6, 7, 8
* Competitive: Tryouts required and uniform must be returned within 2 weeks of end of program to receive deposit refund If you have any questions contact: Phil Schmitz, M.A. Sports Psychology – Athletic Director After School Sports 925-943-5899 x2661 email:
[email protected]; Web-site: www.walnutcreekrec.org
Student Information Please Print and Use Ballpoint Pen
Student's Name:________________________________________
M
F Grade:________ Birth Date:__________
Address: __________________________________________ City: __________________________ Zip:_____________
Fathers Name: _____________________ Home Phone: ____________________ Other: __________________________ Mothers Name: ____________________ Home Phone: ____________________ Other: __________________________ Parent Email: ______________________________________________________________________________________
Emergency Contact Information Emergency Contact #1: ________________________________________________ Phone: _______________________ Emergency Contact #2: ________________________________________________ Phone: _______________________ **Medical Emergency Information** Medical Plan: _____________________________________________ Medical Number: __________________________ Medical Problems/Allergies: __________________________________________________________________________ Doctors Name: ______________________________________________
Phone: __________________________
Dentists Name: _____________________________________________
Phone: __________________________
I hereby authorize any representative of the After School Sports Program, in the event of an emergency, to call the listed doctors, ambulance and/or take my child to the nearest hospital. I also consent to any x-rays, examinations, anesthetics, mental, dental, or surgical diagnosis or treatment and hospital care to be rendered to my child under general or special supervision and upon the advise of a surgeon, dentist, or the listed physician. Parent/Guardian Signature: _______________________________________________ Date: ______________________ Automobile Insurance Policy If you plan to help the program by transporting our student athletes, then the vehicle used to transport the students to and from After School Sports Events, must have insurance coverage required by California State Law. Insurance Name: _____________________________________________ Policy Number: ________________________ Waiver of Liability I understand that the After School Sports Events are active and physical and that participation will incur certain risks, which may result in serious personal injury and/or property damage as a consequence. I understand that this may include injury to all parts of the body. In addition to the risks to the body or personal property, there are unpredictable dangers involved in the After School Sports Program. I consent to the below person’s participation in these activities and agree on behalf of said person and the undersigned that we assume the risk of accident or injury sustained from whatever cause in connection therein and release the City of Walnut Creek and their officers, agents, volunteers, independent contractors and employees from being liable for such accident or injury. I also understand that • NO REFUNDS will be given unless specific sport is canceled. • Enrollment in competitive programs does not serve as a confirmation that the student has been selected for the team. Parents and students will be notified if students have been selected for the team after tryouts have been completed. Any students who do not make the team will either be refunded in full or have the opportunity to enroll in the intramural team. • Uniforms must be returned within two weeks from the end of the program to receive a uniform deposit refund.
Parent/Guardian Signature: ________________________________________________ Date: _____________________
Parent and High School Student Participation Parent and High School student participation is very helpful. Check any of the following areas that you are able to volunteer to help in the event the Coach requests assistance. 1. Organizing carpools
4. Practice coach
2. Telephone calls
5. Referring
3. Assistant coach
6. Scorekeeping
Volunteers Name: ________________________________________________ Phone Number: ____________________ Relationship to Student______________________________________________________________________________
Student’s Name____________________________________________________________________________________
Total Payment Enclosed Cash
$___________
Check (made payable to CITY OF WALNUT CREEK) Check # _______________
CREDIT CARD PAYMENT ONLY: Name on Card (Print)_____________________________________________________________ Number __________________________________________________________ Exp. ____________________________ Authorizing Signature _______________________________________________________________________________ All registration forms and payments will be processed upon receipt. Enrollment in competitive programs does not serve as a confirmation that the student has been selected for the team. Parents and students will be notified if students have been selected for the team after tryouts have been completed. Any students who do not make the team will either be refunded in full or have the opportunity to enroll in the intramural team.
