2016 PORT DICKINSON COMMUNITY ASSOCIATION MEMBERSHIP APPLICATION 786 Chenango Street Binghamton, NY 13901 Email - [email protected] Website - portdickcommunity.org PARENT/GUARDIAN INFORMATION Parent(s)/Guardian(s) Name: Phone: Cell Phone: e-mail: Current address: City: State: ZIP Code: EMERGENCY CONTACT Name of a relative not residing with you: Address: Phone: City: State: ZIP Code: SHIRT SIZES - PLEASE LIST HOW MANY OF EACH (ONE SHIRT PER CHILD) Youth - M Adult - S Adult - L Youth - L Adult - M Adult - XL

CHILD INFORMATION (1) (REQ’D FOR PDCA FUNDING) ETHNICITY CODES: 1-WHITE 2-BLACK/AFRICAN AMERICAN 3-HISPANIC/LATINO 4-ASIAN 5-AMERICAN INDIAN/ALASKAN NATIVE 6-TWO OR MORE RACES CHILD 1: Ethnicity Code (1-6): Date of birth: Age: Gender: M F Current Grade: ACTIVITIES YOUR CHILD WOULD LIKE TO PARTICIPATE IN Basketball (K-2)-Starts in January OR T-Ball (5-6) The Grades 3-6 teams-Starts in Oct. (Child must be 5 AND in Kindergarten) Little League (9-10)(11-12) (There are try outs to make this team) (Girl 3-4) (Girl 5-6) (Boy 3-4) (Boy 5-6) Combined Civic Summer Fun (full day Coach Pitch (7-8) Softball pgm) – EXTRA FEE (Child must be 5 AND in Kindergarten) Soccer Swimming Farm League (9-10) (11-12) (Child must be 5 AND in Kindergarten) CHILD INFORMATION (2) (REQ’D FOR PDCA FUNDING) ETHNICITY CODES: (1) WHITE (2) BLACK/AFRICAN AMERICAN (3) HISPANIC/LATINO (4) ASIAN (5) AMERICAN INDIAN/ALASKAN NATIVE (6) TWO OR MORE RACES CHILD 2: Ethnicity Code (1-6): Date of birth: Age: Gender: M F Current Grade: ACTIVITIES YOUR CHILD WOULD LIKE TO PARTICIPATE IN Basketball (K-2)-Starts in January OR T-Ball (5-6) Little League (9-10) (11-12) The Grades 3-6 teams-Starts in Oct. (Child must be 5 AND in Kindergarten) (There are try outs to make this team) (Girl 3-4) (Girl 5-6) (Boy 3-4) (Boy 5-6) Combined Civic Summer Fun (full day Coach Pitch (7-8) Softball pgm) – EXTRA FEE (Child must be 5 AND in Kindergarten) Soccer Swimming Farm League (9-10) (11-12) (Child must be 5 AND in Kindergarten) CHILD INFORMATION (3) (REQ’D FOR PDCA FUNDING) ETHNICITY CODES: (1) WHITE (2) BLACK/AFRICAN AMERICAN (3) HISPANIC/LATINO (4) ASIAN (5) AMERICAN INDIAN/ALASKAN NATIVE (6) TWO OR MORE RACES CHILD 3: Ethnicity Code (1-6): Date of birth: Age: Gender: M F Current Grade: ACTIVITIES YOUR CHILD WOULD LIKE TO PARTICIPATE IN Basketball (K-2)-Starts in January OR T-Ball (5-6) Little League (9-10)(11-12) The Grades 3-6 teams-Starts in Oct. (Child must be 5 AND in Kindergarten) (There are try outs to make this team) (Girl 3-4) (Girl 5-6) (Boy 3-4) (Boy 5-6) Combined Civic Summer Fun (full day Coach Pitch (7-8) Softball pgm) – EXTRA FEE (Child must be 5 AND in Kindergarten) Soccer Swimming Farm League (9-10) (11-12) (Child must be 5 AND in Kindergarten)

CHILD INFORMATION (4) (REQ’D FOR PDCA FUNDING) ETHNICITY CODES: (1) WHITE (2) BLACK/AFRICAN AMERICAN (3) HISPANIC/LATINO (4) ASIAN (5) AMERICAN INDIAN/ALASKAN NATIVE (6) TWO OR MORE RACES CHILD 4: Ethnicity Code (1-6): Date of birth: Age: Gender: M F Current Grade: ACTIVITIES YOUR CHILD WOULD LIKE TO PARTICIPATE IN Basketball (K-2)-Starts in January OR T-Ball (5-6) Little League (9-10)(11-12) The Grades 3-6 teams-Starts in Oct. (Child must be 5 AND in Kindergarten) (There are try outs to make this team) (Girl 3-4) (Girl 5-6) (Boy 3-4) (Boy 5-6) Combined Civic Summer Fun (full day pgm) – EXTRA FEE Coach Pitch (7-8) Softball (Child must be 5 AND in kindergarten) Soccer Swimming Farm League (9-10) (11-12) (Child must be 5 AND in Kindergarten)

PLEASE LET US KNOW WHAT EVENTS YOU WOULD BE ABLE TO HELP US WITH Field Maintenance Y N Concession Stand Y N Park Clean Up Days Y N Raffle Ticket Sales Y N Chicken BBQ Y N Serving as a Board Member Y N Athletics Coaching in: Baseball Y N Fundraising Committee Y N Athletics Coaching in: Soccer Y N Softball Y N Summer Fun Y N T-Ball Y N Basketball Y N

*I/we, the parents/guardians of the above named children, hereby give my/our approval to participate in the Port Dickinson Community Association activities, including transportation to and from the activities. I/we do hereby waive, release, absolve, indemnify and agree tohold harmless the local Community Association, the organizers, sponsors, supervisors, participants, and persons transporting my/our children to or from activities, for any claim arising out of an injury to my/our children, except to the extent covered by accident or liability insurance.

* I/we understand it is solely my/our responsibility to advise Port Dickinson Community Association coaches and teachers of any injuries or health risks, including food allergies, relating to my child and in said case, parents, not Port Dickinson Community Association coaches/teachers will assume responsibility for treating immediate food allergy reactions.

*I/we will furnish the Port Dickinson Community Association with a birth certificate to verify child’s age if requested or needed.

*I/we the parents/guardians do hereby pledge our assistance to the Port Dickinson Community Association whenever called upon.

Parent (Guardian) Signature:______Date:______

FOR ASSOCIATION USE ONLY Year: 2016 Date: Amount Paid: Cash

Cost of yearly membership: $75 Check Number: