Department of Parks and Recreation
Derrick France, Director
Parks and Recreation
247 Fore Dr., Suite 201
Gate City, VA 24251
Phone: 276-452-2442
Fax: 276-452-4554
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2023 Scott County Recreation Dept. Youth Basketball Registration Application
Name:   Date of Birth:


City:   State:   Zip:

Phone:   School:   Grade:

Sex:   Name of Last Year's Coach:   Youth/Adult T-Shirt:


Having been informed of the organization of Recreation Activity Programs to provide supervised games for the youth of Scott County, Virginia, I/We, the Parents/Guardian of the above child do hereby give my/our approval to his/her participation in any and all of the activities during the current season and/or any seasons thereafter. I/We assume all the transportation to and from these activities, and I/We do hereby release, absolve, indemnify and hold harmless any of the organizers, sponsors and supervisors. In case of injury to my/our child, I/We hereby waive all claims against the organizers, sponsors, or any of the supervisors/coaches appointed by them. I/We likewise release from responsibility any person transporting my/our child to and from these activities. I/We understand that we as parents/guardians are responsible for child/children at all times in terms of his/her/their individual safety and any damage that facilities may incur due their presence. I/We also understand that we are responsible for any of our children that we allow to be present at any activity who is/are not registered for said activity. It is understood that children not participating and registered are better left elsewhere as this is not a baby/child sitting or day care service.

Scott County cannot provide medical insurance for injuries to participants.
Does your child have medical insurance coverage?   Yes  No

If yes, list the name of the insurance company:  

and ID or policy number:  

In the event of injury please contact me at: (emergency telephone number). If I cannot be reached, I hereby consent to transportation by ambulance of my child to the nearest medical facility for medical treatment at my expense if deemed necessary by the coach or supervisor of this activity.

I/We understand that assignment of my/our child to any particular team or league by the operators of this program shall be left to the discretion of the supervisors of these programs.

Youth Basketball is available to boys and girls in grades 2-6. Grades 2nd and 3rd will be a CO-ED league and grades 4th thru 6th will be a GIRLS league and BOYS league separately. Cost are: $30 per player and $50 per family. Add $5 for non-county child and $10 for non-county family.


You may mail payment to: Scott County Rec Dept; 247 Fore Dr; Gate City, VA 24251, deliver to the Rec. Dept., or return the payment to your child's school office prior to the deadline. My/Our child is now years old. If you have any questions, please call the SCRD at 276-452-2442.

Parent: Will you coach a team?   Yes No
Parent: Will you work in other capacity?   Yes No

The submission of this form indicates acceptance of the terms and conditions.