Mattoon Hit-Men Proof of Insurance and Liability Waiver

Mattoon Hit-Men Proof of Insurance and Liability Waiver
Athlete's Name:*

First NameLast Name
Athlete's Date of Birth:*

MonthDayYear
Date
Height:*
School:*
Grade:*
Father's Name:*

First NameLast Name
Father's Email:*
example@example.com
Father's Cell Phone:*
Please enter a valid phone number.
Father's Work Phone:
Please enter a valid phone number.
Mother's Name:*

First NameLast Name
Mother's Email:*
example@example.com
Mother's Cell Phone:*
Please enter a valid phone number.
Mother's Work Phone:
Please enter a valid phone number.
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Health Insurance Carrier:*
Insurance Carrier Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Agent's Name:*

First NameLast Name
Agent's Phone Number:*
Policy Number*
Please list any past injuries our staff should be aware of, as well as any allergies to food, medicine, etc. (if none, type NA in the field box):*
I understand that my son is trying out or on the Mattoon Hit Men Baseball Team. There are no refunds on fees already paid. Fees due but not paid and missed practices may result in the player being replaced on the team. I have read and understand what is involved with the Mattoon Baseball Hit Men Team.

Legal disclaimer: This must be signed by a parent or legal guardian before participation will be allowed.

I hereby release Mattoon Hit Men, its Officers, Directors, Coaches and all facility owners for damages or injuries incurred while my son participates in the Hit Men Baseball program and tryouts. I certify that my son is in good health and can participate in all physical activities. Should an injury occur, I agree to allow him to be treated by a licensed physician or paramedic.
Signature of Parent / Guardian*

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Name*

First NameLast Name
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Mattoon Hit-Men Proof of Insurance and Liability Waiver

Insurance Information