Fall 2022: NYS Rascal Student Volunteer form
Please fill out this form if you are an 8th grader or high school student interested in volunteering for the NYS Rascal program.
Sign in to Google to save your progress. Learn more
Last name *
First name *
List your NYS team/ other basketball affiliation:  *
Contact number: please put in the format (xxx) xxx-xxxx *
Contact email address *
Please check off your session availability. *
Required
We realize that your time is valuable and you may not be able to the entire session. Please list any Sundays that you may not be available to work: *
Authorization for third party to consent to treatment of a minor lacking capacity to consent and photo release agreement.
We, the parents/guardian of the player participating as designated in the application, in the event our minor child becomes ill or sustains an injury while in the care or under the supervision of the managers, coaches, or other representatives of Norwalk Youth Sports , they are given permission to administer first aid for her or his relief. I understand an attempt will be made to contact me/us at the time of the accident or illness if time permits. If it is not practical to return her or him to us or to receive our instructions for their care consent is given to have any medical  or surgical treatment performed as any licensed  physician deems necessary for the relief of pain and to preserve their life and health. I/we hearby hold harmless Norwalk Youth Sports, the Southeast Japanese School and Community Center, its members, coaches, and staff for any liability, including injuries, in connection with the Rascals Basketball Program. I/We agree to abide by the rules and regulations of the NYS Rascals Basketball program. I also grant the Norwalk Youth Sports “NYS” Rascals Program, a club organized under the Southeast Japanese School and Community Center “SEJSCC” the right to use any photographs or video taken of me and my family while participating with and/or attending the Rascals program. I authorize the NYS, SEJCC, its assignees, and transferees, to copyright, use and publish such photographs in print and/or digital form. I agree that NYS and /or SEJSCC may use such photographs with or without name for any lawful purpose, including, for example such purposes, including, for example, such purposes as publicity, illustration, advertising or web content, I have read and understood the above release and agree to its conditions without any future consideration. *
COVID19 statement and waiver
Southeast Japanese School & Community Center 14615 Gridley Road, Norwalk, CA 90650 • (562) 863-5996Liability Release Waiver - COVID-19.  (A PDF of the form is located on the Rascals website for printing. One will be provided at check in on the first day of the player's program if you do not have access to a printer or need a hard copy of this form.).                                      In consideration of my participation in the Southeast Japanese School (SEJS) and Community Center activities, I, the undersigned1. Confirm that I have taken good note of the SEJS COVID PROTOCOLS and hereby undertake to comply with it. 2. Acknowledge and agree to the following:a. I am aware of the existence of the risk my participation in the SEJS activities and my participation may cause illness such as, COVID 19.b. I have not experienced symptoms such as fever, fatigue, difficulty breathing, cough, loss of taste or smell or any other symptoms relating to COVID-19 within the last 14 days.c. I have not been, nor any of my family members, friends or co-workers whom I live or work with been diagnosed to be infected of COVID-19 virus within the last 30 days.3. And, following the pronouncements above I hereby declare the followinga. I am fully and personally responsible for my own safety and actions while and during my participation and I recognize that I may in any case be at risk of contracting COVID-19.b. With full knowledge of the risk involved, I hereby release, waive, discharge the SEJS of any and all liabilities, claims, demands, actions and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any SEJS activities while in, on, or around the premises or while using the facilities that may lead to unintended exposure or harm due to COVID-19.By signing below, I acknowledge that I have read the foregoing Liability Release Waiver and understand its content. I am at least (18) years old and fully competent to give my consent. I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed. I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same and free from any inducement or representation.This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted. *
Volunteer hours verification
Please note: If you need Community Service hours verification from the NYS Rascals Program, please send your name directly to Kelly Katayama-Johnson. Email mrskj1@me.com : Please give your name (First/Last or how you want it to appear in the letter), your high school, and the organization for verification for hours of service.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy