Youth Sports Registration Form printable pdf download

Youth Sports Registration Form

A copy of the player’s Birth Certificate must be submitted with this form.

Player’s Full Name as appears on Birth Certificate

: ________________________________________________________

Nickname: _______________________

Male___ or Female___

Age: ____

Birth Date: _______________

Parents or Guardians: _____________________________________________________________________________________

Home Phone: ______________ Cell Phone: ______________

Email: _____________________________________________

Address: _______________________________________________________________________________________________

City: ______________________________________________________

State: _____

Zip Code: _________

Physician: __________________________________________________

Physician Phone: _______________________

: _______________________________________________________________

Any Medical Conditions, Allergies, ETC

______________________________________________________________________________________________

*Please inform the coach of these conditions prior to the first practice

Sport: __________________________________

Season: __________________________

Fee: ______________

Sport Fees:

$35.00 Youth Football & Cheerleading

Uniform Size:

Youth Extra Small

Youth Small

$55.00 Youth Basketball

Youth Medium

Youth Large

$75.00 Boy’s Lacrosse

Adult Small

Adult Medium

$75.00 Girl’s Lacrosse

Adult Large

Adult X-Large

Other Size: _________________

Recreation Scholarship Fund:

Yes, I would like to contribute _____$1.00, _____$2.00 ______$5.00 or other $___________ to the Recreation scholarship

fund. This fund allows children from the Town of Farmville to attend recreational programs in our Town who financially may

not be able to participate. Please include this with your payment. Thank you for your donation!

Parent/Guardian Participation:

I/We understand that Recreation Department conducts fund raising and volunteering activities in addition to the registration fee

and that each player/parent is strongly encouraged and expected to participate. I/We are willing to participate in the following

activities for the Farmville Recreation Department’s Youth Sports Programs.

Check all that apply:



Coach

Fund Raise

Concessions

Maintain Fields

Gate Attendant

Assist Officials

Consent/Waiver Agreement:

I/We consent to our child participating in the Farmville Recreation Department Programs. In participating in Recreation Programs, sponsored by The Town

of Farmville, I hereby acknowledge that I/We understand that there are risks of accidents resulting in bodily harm arising out of those activities. I/We

understand that Recreation activities are planned with the safety of the participants in mind. In case of emergency, accident or illness, if I/We am not present

I/We hereby give our permission for the coach or representative of the Recreation Department to obtain any required medical attention my child may need.

I/We will notify the coach of any physical limitations (allergies, hearing, sight, etc) or other additional information they need to know about my/our child.

I/We further acknowledge that my child has the physical capacity reasonably necessary to engage in Recreation activity for which I have enrolled. I/We

agree to be the party responsible for all medical expenses which are incurred in my behalf. It is understood and agreed that the Town, it’s Mayor, Town

Council, Boards, employees, volunteers and agents shall be held harmless against all claims, damages, loss or expenses including attorney’s fees arising out

of or resulting from participation in recreation programs. I/We agree any pictures taken may be used for future promotions for the Town of Farmville.

___________** I have read the above waiver and understand the contents**

_____________________________________________________________________________________________

______________________________________

SIGNATURE (PARENT OR GUARDIAN)

Date

OFFICE USE Only: Cash__ Check #__________ Amount Paid__________ DATE: _____________INT:_____________