Youth Activities: Basketball Basketball Sign-up Basketball Sign-up Student Information Name * Name First First Last Last Age * Grade * 1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade T-Shirt Size * Youth X-SmallYouth SmallYouth MediumYouth LargeAdult X-SmallAdult SmallAdult MediumAdult Large Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Cell Phone * Secondary Cell Phone plus1 Add Another Child minus1 Remove Child Emergency Contact Information Name * Name First First Last Last Phone * Email * Release Liability I, PARENT/GUARDIAN, give CHILD permission to participate in the Ainsworth Youth Basketball program and claim responsibility for this minor. I release and hold harmless all other contestants, coaches, sponsors, tournament officials, and the City of Ainsworth and the Ainsworth Community Schools, its employees, students, and officials from all claims for personal injuries, lost or stolen property and for damages incurred in connection with his/her participation in the Ainsworth Youth Basketball program. Signature * signature keyboard Clear Date In the event my child is injured or becomes ill during a basketball event, I give a representative of the program permission to give aid to my child to the best of their ability. I understand that a parent or guardian will be called ASAP. Signature * signature keyboard Clear Date PLEASE NOTE Once you press the submit button, you will be redirected to Payport through the nebraska.gov website. You must make the payment for your child's submission to be complete. If you have any questions, please reach out to us at admin@cityofainsworth.com. Submit If you are human, leave this field blank.