2. First Name*
3. Last Name*
5. Email Address*
6. Phone Number*
8. Participant is the same as above

   1. Yes
10. Participant First Name
11. Participant Last Name
13. Youth Phone*
14. Youth Email*
16. School
17. Grade:*
19. Reply Email
20. Date of Birth**
    Date of Birth*
21. Ethnicity:

    1. Hispanic or Latino
    2. White or Caucasian
    3. Black or African American
    4. American Indian or Alaskan Native
    5. Asian
    6. Prefer not to say
23. School
25. Grade:*

    1. 7TH
    2. 8TH
    3. 9TH

    1. 10TH
    2. 11TH
    3. 12TH
26. How did you hear about this program? Please place a to which category (or categories) apply to you:*

    1. Postcard/Direct Mailing
    2. Social Media
    3. School
    4. Town’s Website
    5. Email
28. Mailing Address
    Street, City, State, Zip
30. Guardian 1:
31. Guardian 1 Cell Phone:
32. Guardian 1 Email:
34. Guardian 2:
35. Guardian 2 Cell Phone:
36. Guardian 2 Email:
38. Emergency Contact Name*
    Home Phone & Cell Phone
40. The following have permission to pick up my child:*
    Name & Relationship
41. Food Allergies or Other Health Concerns:*
42. NEED A RIDE?*

    1. Yes
    2. No

    Roundtrip transportation is available from the Flanders Youth Center. 
    Departs: 4:15pm
    Returns: 7:30pm

44. I give permission for my child (ren)**

    1. I agree - BASKETBALL @ SYS

    I give permission for my child   to attend the Town of Southampton Youth Bureau’s Basketball Clinic program at Southampton Youth Services (SYS), 1370a Majors Path from January 16th 2026 - May 15th 2026. If transportation is needed, I also give my child permission to be transported to/from the designated bus stops listed on this form. I hereby shall release liability, waive any claims against, indemnify, defend and hold harmless the Town of Southampton, its officers, employees, contractors, agents and representatives from and against any and all demands, liabilities, losses, damages, expenses (including reasonable attorney’s fees) and judgments relating to or arising from my child’s participation in the Town of Southampton Youth Bureau’s Basketball Clinic program. I certify that my child’s health and physical condition are appropriate for participation in these physical activities. In the event of a medical emergency and I cannot be reached, I authorize the Town of Southampton Youth Bureau staff to seek emergency medical treatment. I also consent to photographs and video being taken of my child, understanding they may be used for promotional purposes.

46. Service (Convenience) Fee:

    A convenience fee of 2.5%, with a minimum fee of $1.95, will be charged by CSG Forte for transactions made with a Visa, MasterCard, Discover, or American Express card. Your personal information will not be shared with marketers or unaffiliated third parties.

48. Registration Fee*
    -- Select One --$50/13 sessions - $50.00
49. Cost of Activity
Leave This Blank:


55. Calculate Totals Proceed to Checkout

* indicates a required field