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Home My WebLink About34TH Annual HI-PAL Winter Basketball Classic (Packet)October 22, 2014 Dear Coaches/Team Representatives: RE : 34TH Annual HI -PAL Winter Basketball Classic Welcome to the 34th Annual HI -PAL Winter Basketball Classic, cosponsored by the County of Hawai'i Parks and Recreation, Recreation division. This year's event, held in Hilo, will begin on Friday, December 26th, 2014 and end on Monday, December 29th, 2014. PLEASE READ THE FOLLOWING INFORMATION In this packet, please find the following : Rules and Regulations; Eligibility Affidavit Form (roster); Waiver Forms for players; age eligibility information; and "'Click It Or Ticket" pledge form. PLEASE COMPLETE ALL FORMS! Waiver form and Eligibility Affidavit Form (roster) - Each new player will need a copy of his/her birth certificate attached to their Waiver Form. Previous participants should have a copy of their birth certificate on file with the Hawai'i Police Department HI -PAL office. Please indicate on the form of previous participation. Birth certificates will be returned upon request. Eligibility deadline is December 31, 2014. Eligibility Affidavit Forms (rosters) must be received by November 28, 2014. This is to confirm your team's participation in the tournament. NO ROSTER! — NO PARTICIPATION! Rosters and forms may be sent to (or dropped off at): 2014 HI-PAL/P&R Winter Basketball Classic c/o Parks & Recreations 799 Pi'ilani Street Hilo, HI 96720 The game schedules will be made available approximately 2-3 weeks prior to the start of the tournament. Each team will play a minimum of three games. Thank you for your continued participation in this 34th annual tournament. For questions and further assistance, please contact the East Hawai'i HI -PAL office at 961- 8121. HI -PAL LEAGUE AGE REQUIREMENTS FOR THE YEAR 2014 Please use this as a guide to make sure the players are in the correct age division. Match the year your player was born and use the chart below to determine his or her division. For further information or questions, please contact the HI -PAL office in Hilo at 961-81211 or in Kona at 326-4646, ext 258. BIRTH YEAR LEAGUE AGE GROUP 2008/2009 5/6 DIVISION 2006/2007 7/8 DIVISION 2004/2005 9/10 DIVISION 2002/2003 11/12 DIVISION 2000/2001 13/14 DIVISION HAWAI'I POLICE DEPARTMENT 349 KAPI'OLANI STREET H I LO, HAWAII 96720 PHONE FAX AREA 1 (808) 961-8121 (808) 961-8845 AREA 11 (808) 326-4646 ext 258 (808) 327-3653 HI -PAL TEAM ELIGIBILITY ROSTER CLUB: AGE GROUP: PARTICIPANT BIRTHDATE GRADE UNIFORM # W BC T-SHIRT SIZE I CERTIFY THAT THE DATES OF BIRTH OF THE PARTICIPANTS LISTED ABOVE AND CORRECT AND HAVE BEEN SUBSTANTIATED BY BIRTH CERTIFICATES EXAMINED BY ME; THAT THE ADDRESSES OF EACH PARTICIPANT IS CORRECT AND EACH PARTICIPANT LIVES WITHIN THE BOUNDARIES. SIGNATURE OF AUTHORIZED CLUB OFFICIAL I DATE I TIME I PHONE NO. EMAIL SIGNATURE OF HI -PAL DIRECTOR HPD/HIPAL-009 REV 3-11-09 RETENTION HAWAII POLICE DEPARTMENT AT RISK: YES NO HAWAII ISLE POLICE ACTIVITIES LEAGUE PLEASE PRINT AND COMPLETE ALL INFORMATION TEAM NAME AGE DIVISION PERSONAL INFORMATION NAME OF PARTICIPANT (Last, First, Middle Initial) AGE BIRTHDATE RES PHONE MAILING ADDRESS CITY STATE ZIP CODE SCHOOL GRADE FATHER'S NAME RES PHONE BUS PHONE CELL MAILING ADDRESS CITY STATE ZIP CODE MOTHER'S NAME RES PHONE BUS PHONE CELL MAILING ADDRESS CITY STATE ZIP CODE LEGAL GUARDIAN'S NAME RES PHONE BUS PHONE CELL MAILING ADDRESS CITY STATE ZIP CODE ARE YOU CURRENTLY RECEIVING GOVERNMENT SUBSIDY? ❑ YES ❑ NO ARE YOU CURRENTLY RESIDING IN GOVERNMENT HOUSING? ❑ YES ❑ NO ARE YOU A SINGLE PARENT FAMILY? ❑ YES ❑ NO FOSTER CARE? ❑ YES ❑ NO COURT REFERRAL? ❑ YES ❑ NO ❑ N. HILO ❑ S. KOHALA ❑ KA'U ❑ S. KONA I ❑ PAPAIKOU l ❑ HONOMU I ❑ KEAUKAHA ❑ HAMAKUA ❑ N. KOHALA ❑ PUNA ❑ WAINAKU I ❑ PEPEEKEO I ❑ HAKALAU I ❑ PANAEWA PHYSICAL DISABILITY, IF ANY; I give consent for your Agency to refer my child if injured or ill, to my family physician when I cannot be reached. Where there is no family physician available, the rlisr.ratinn fnr —1— inn of n rinrtnr will ha loft to tha nnanr.v IN CASE OF EMERGENCY, CONTACT RES PHONE BUS PHONE CELL PHYSICIAN'S NAME OFFICE PHONE NUMBER MEDICAL INSURANCE COVERAGE POLICY NUMBER EXPIRATION DATE Iriy0yATyyAIIarDIE mr ofyirearhrA PARENT(S) OR LEGAL GUARDIAN: ON BEHALF OF (MINOR), FOR AND CONSIDERATION OF SAID MINOR BEING PERMITTED TO PARTICIPATE IN THE HI -PAL SPONSORED ACTIVITIES, HEREBY EXPRESS;Y AGREE(S) A That there is a substantial value and benefit to be derived by Minor in TYPE OF ACTIVITY FROM -TO (DATE) participating in this activity sponsored by the COUNTY B That they shall forever release and waive all rights to bring suit or claims against and will indemnify and hold harmless, the County of Hawaii, it's officers, agents and employees, HI -PAL program, the Hawai'i Police Department, or any representative, sponsor, manager, coach, trainer, or person who is in any manner connected with the operation of the HI -PAL Program, an account of any and all claims, demands, loss of services, or expenses for property damage, and/or personal injuries, that may arise as a result of said minor's participation in or transportation to and from the subject HI -PAL activity. C That COUNTY is not to be held liable for death or injuries resulting during period when MINOR is transported to ACTIVITY by persons other than employees of the COUNTY. D I To give consent to allow MINOR to actively participate in ACTIVITY. E That PARENT(S) recognizes and understands that participation in ACTIVITY involves risk of death, personal injury, and/or property damage, commonly inherent in such activity F That MINOR, through PARENT, or LEGAL GUARDIAN, voluntarily chooses to participate in ACTIVITY, to which action PARENT or LEGAL GUARDIAN, gives approval and consent. G That said MINOR is in reasonable good physical and mental health, such that MINOR can safely participate in ACTIVITY. H To notify a representative from the HI -PAL Program if there is any change in MINOR's physical and/or mental condition such that MINOR cannot safely participate in ACTIVITY. Dated: 20 Hawai'i Father Mother Legal Guardian H PD/H I PAL -00 1 B REVISED 3-11-09 RETENTION 3 YEARS to l4( CLICK IT CLICK CLICK IT I - PAL � TICKET TICKET TIw171 A Lbw You Car, 'wilk ""CLICK IT OR TICKET" PLEDGE OCCUPANT PROTECTION AGREEMENT Being the parent/legal guardian of the participant listed below I pledge the following: 1. That I am aware of the State of Hawai' i laws requiring the use of seat belts for: • All front seat passengers; • All back seat passengers; • All children under four years of age must be properly restrained in a child safety seat, and ages four to seven in a booster seat. 2. That I, my children, and all passengers of any vehicle that I operate, will be properly restrained by a seat belt or child restraint system as required by laws. Print Name (Parent/Guardian) Signature/Date Being a participant of this Click It or Ticket event, I pledge the following: 1. That I am aware of the State of Hawai' i laws requiring the use of seat belts for: • All front seat passengers; • All back seat passengers; • All children under four years of age must be properly restrained in a child safety seat, and ages four to seven in a booster seat. 2. That I, as a youth or teen between the ages of 4 and 17, I will always properly use my seat belt, whether a front or back seat passenger and that I will encourage all that ride in a vehicle with me to also use their seat belts as required by law. Print Name (Youth/Participant) Signature/Date ALL YOUTH ... ALL TEENS...ALL SEATS... BUCKLE UPI. A LAW YOU CAN LIVEWITH