3748 State Route 7, Chesapeake, Ohio 45619
tristatedevelopmentalservices@gmail.com www.tristatedevelopmentalservices.org 740-891-4263
Guardian/Parent's Name
*
First Name
Last Name
Guardian/Parent's Name
First Name
Last Name
Child's Name
*
First Name
Last Name
Date of Birth
Athlete's Shirt Size
*
Please Select
Youth Small
Youth Medium
Youth Large
Youth X Large
Adult Small
Adult Medium
Adult Large
Adult XLarge
Adult 2X
Adult 3x
Adult 4x
Child 1
Preferred Jersey Number
Child 1
Child's Name
First Name
Last Name
Date of Birth
Athlete's Shirt Size
Please Select
Youth Small
Youth Medium
Youth Large
Youth X Large
Adult Small
Adult Medium
Adult Large
Adult XLarge
Adult 2X
Adult 3x
Adult 4x
Child 2
Preferred Jersey Number
Child 1
Child's Name
First Name
Last Name
Date of Birth
Athlete's Shirt Size
Please Select
Youth Small
Youth Medium
Youth Large
Youth X Large
Adult Small
Adult Medium
Adult Large
Adult XLarge
Adult 2X
Adult 3x
Adult 4x
Child 3
Preferred Jersey Number
Child 1
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Phone Number
Format: (000) 000-0000.
Father's Phone Number
Format: (000) 000-0000.
Mother's E-mail
example@example.com
Father's E-mail
example@example.com
What Programs Are You Interested In?
Karate
Baseball
Basketball
Kickball
Volleyball
Life Skills
Job Skills
Crafts
Gaming
Family Support Group
Special Olympics
Yoga
Preferred Method of Contact
Phone Call
Text Message
Email
Please mark the Tristate Developmental Service pages you follow.
Our Facebook Page: https://www.facebook.com/tristatedevelopmentalservices
Our Facebook Group: https://www.facebook.com/share/g/14QSfdh1Lgy/
Our Website: https://www.tristatedevelopmentalservices.org
Informed Consent/General Release- Participants PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR AGREEMENT. NOTE: THIS FORM INCLUDES A RELEASE OF LIABILITY. Since participation in youth sports activities can be dangerous, Tristate Developmental Services requires that all participants (and their adult parent(s) or guardians) assume all risks associated with activities by signing this general release. For and in consideration of my child being permitted to participate in Tristate Developmental Services sports and activities, I hereby voluntarily release, discharge, waive and relinquish any and all claims or actions for damages for personal injury, permanent disability, death, or property damage which I or my child may have, or which may here after accrue to me or my child, as a result of my participation in activities during play and while I am at the facility while others play or for any other reason. This release is intended to discharge, in advance, Tristate Developmental Services, it’s officers, employees and agents, and the owners and maintainers of any facility used for activities, from any and all liability arising out of or connected in any way with my child’s participation in sports or activities, even though that liability may arise out of negligence or carelessness on the part of Tristate Developmental Services, its officers, agents or employees, or the owners or maintainers of any facility used by Tristate Developmental Services for sports or activities. I further understand that serious accidents occasionally occur during sports and activities, and that participants occasionally sustain serious personal injuries, death or property damage as a consequence thereof. Knowing the risks, I have voluntarily applied for my child to participate in the activity and thereby agree to assume those risks to release and hold harmless Tristate Developmental Services, its officers, employees or agents, or the owners or maintainers of any facility used by the Tristate Developmental Services for sports or activities, who (through negligence or carelessness) might otherwise be liable to me or to my child (or my heirs or assigns) for damages. I further understand and agree that this release, discharge, waiver, and assumption of risk is to be binding on my and my child’s heirs, executors, administrators, and assigns. I further agree to indemnify and to hold harmless Tristate Developmental Services, its officers, employees and agents, or the owners or maintainers of any facility used by the Tristate Developmental Services for sports or activities, for any loss, liability damage, cost or expense which may incur as a result of any injury or property damage I or my child may sustain while participating in the activity. I agree to comply with the program’s stated and customary terms and conditions for participation according to the Tristate Developmental Services. If I observe any significant change with regards to my child’s readiness for participation in the program, I will remove my child from the program immediately. I have read this Informed Consent/General Release, fully understanding its terms, that I give up substantial rights by signing it, and sign it voluntarily. DO NOT E-SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT. By my eSignature below, I certify that I have read, fully understand and accept all terms of the foregoing statement. Please signify your acceptance by entering your full name in the box below.
*
I accept the terms listed in the agreement above
Full Name of Parent/Guardian Signature
*
First Name
Last Name
Parent's E-Signature
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