Eureka Youth Baseball/Softball Registration Form

Player's Name:*

First NameMiddle NameLast Name
Player's Date Of Birth:*

MonthDayYear
Player's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:*

Area CodePhone Number
Home Email*
Mother's Name

First NameLast Name
Mother's Cell

Area CodePhone Number
Mother's Email
Mother's Cell Provider
Father's Name

First NameLast Name
Father's Phone

Area CodePhone Number
Father's Email
Father's Cell Provider
T-Shirt Size*

Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult Large
SELECT YOUR CHILD'S INTEREST AND GRADE LEVEL*
Authorization For Emergency Treatment

By submitting this form you give your consent for your child's participation in any and all Eureka Youth Baseball/Softball functions or activities. In the event of any injury or sickness occurring during any Eureka Youth Baseball/Softball functions or activities, you authorize any official(s) to administer first aid and if necessary to transport your child to the nearest emergency treatment.

You release Eureka Youth Baseball/Softball and any person(s) connected with Eureka Youth Baseball/Softball of any responsibility from accident or injury incurred as a result of his participation in any and all activities, including transportation to and from any Eureka Youth Baseball/Softball functions or activities.

You certify that you child has been given a physical examination and is physically able to participate in all related activities. Please notify in writing any prescribed medications and / or physical conditions of which the Eureka Youth Baseball/Softball coaching staff should be aware of are listed below.
Are there any medical conditions the staff needs to be aware of?
Comments:
In Case Of Emergency
Point Of Contact:*
Contact Number:*
Signed: Parent
Date:

MonthDayYear
$30.00 League Fee for all players- Please make checks out to Eureka County Juvenile Probation.

Payments are accepted at the Juvenile Probation Office 10 S. Main St (Credit Card, Cash, Or Check)
Signature
Should be Empty: