Lombard Park District

ATHLETICS FORM Youth Sports Information Form This form is required for all children participating in soccer, basketball, T-ball, and girls softball. This form can be dropped off, mailed or faxed to Sunset Knoll Recreation Center: 820 S. Finley Road, Lombard, IL 60148. Fax: (630) 620-0762 Sport: __________________________________ Season: __________________________________ School: __________________________________ Grade: ___________________ Players Full Name: ________________________________________________________________ Phone: __________________________________ Sex: M F Address: ___________________________________________________________________________ City: _____________________________________ Zip: ______________________ E-mail: _____________________________________________________________________________ Date of birth: ___________________________ Age: _____________________ On travel/school team? Yes No Number yrs in sport: ________ Shirt Size: ______________________________ Height: __________________ Parent/Guardian name: __________________________________________________________ Phone: _____________________________________________________________ Alternate contact name: _________________________________________________________ Phone: _____________________________________________________________ Illnesses, allergies, or other medical conditions: ________________________________ Coach Request: ____________________________________________________ Friendship Request (limit one): ___________________________________________________ Evenings player cannot practice: __________________________________ Visit the athletics page at www.lombardparks.com for team formation guidelines. PARENTS/GUARDIANS: If interested in coaching, please complete the following information: For the sport listed on this form, the following parent/guardian can be a: Head Coach Assistant Coach Name: ____________________________________________________________________________ E-mail: _____________________________________________________________ Phone: ___________________________________________________________________________ Preferred practice night: __________________________________________ Have you ever coached this sport? Yes No If you are signing up to be a head coach and have an assistant coach, please include their information (limit one): Name: ____________________________________________________________________________ E-mail: _____________________________________________________________ Phone: ___________________________________________________________________________ PLEASE NOTE: The Lombard Park District conducts criminal background checks on all volunteer coachers. KARATE - ISKC (All Ages) Children and adults universally enjoy learning the art of karate. Classes are taught by Illinois Shotokan Karate Club's expert instructors under the direction of John DiPasquale, four-time National Champion, U.S. Karate National Coach and President of the National Karate Federation of the U.S. Beginner students will not be permitted to register into the current session after the second class. Registration for continuers through advanced students will be accepted after the start date, but the full class fee is required. Uniforms and Belt-Testing options are available through the ISKC instructor. Please note that the Youth, Parent/Child and Adult classes may train together. Fee is per student. Instructor: Club Staff IL Shotokan Karate Location: Sunset Knoll Recreation Center Code Day Belt Date Time R/NR Fee PRE KARATE (AGES 4-7) 210100-01 Th White and up 06/12 - 08/21 4:45 - 5:30 pm $99/$111 YOUTH (AGES 8-14) 210100-02 Th White-Orange 06/12 - 08/21 5:35 - 6:30 pm $99/$111 210100-03 Th Yellow-Green 06/12 - 08/21 6:35 - 7:30 pm $99/$111 210100-04 Th Purple and up 06/12 - 08/21 7:35 - 8:30 pm $99/$111 PARENT/CHILD (7 AND UP) 210100-05 Th White-Orange 06/12 - 08/21 5:35 - 6:30 pm $99/$111 210100-06 Th Yellow-Green 06/12 - 08/21 6:35 - 7:30 pm $99/$111 210100-07 Th Purple and up 06/12 - 08/21 7:35 - 8:30 pm $99/$111 ADULT ( 15 AND UP) 210100-08 Th Beginning Continuing 06/12 - 08/21 8:30 - 9:30 pm $99/$111 210100-09 Th Permission 06/12 - 08/21 8:30 - 9:45 pm $113/$125

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• PARENT/CHILD T-BALL