Shamokin Youth Softball registration

Player's Name

NameSurname
School Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Parent's Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Parent's Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please list below any medical problems, including any requiring maintenance medication (i.e. Diabetics, Asthma, Allergies, Seizures).
Emergency Contact

First NameLast Name
MotherFatherGuardianSisterBrotherUncleAuntCousinOther
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

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I certify that the information in this application is correct, and I agree to abide by the eligibility rules & regulations governing athletics as set forth by X.

I understand that there are certain risks of injury inherent in the practice and play of this sport, as well as in traveling and other related activities incidental to my participation, and I am willing to assume these risks on behalf of me.
Date

MonthDayYear
Date
Player's Signature

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As the parent / guardian of the child name above, I hereby give my full consent and approval for my child to participate as a team member in X Team.

I understand that there are certain risks of injury inherent in the practice and play of this sport, as well as traveling and other related activities incidental to my child's participation, and I am willing to assume these risks on behalf of my child.

I hereby certify that my child is fully capable of participating in the designated sport and that my child is healthy and has no physical or mental disabilities or infirmities that would restrict full participation in these activities, except as listed below.
In addition to giving my full consent for my child's participation, I do accept the usage of my child's photo / video for promotional use in local, regional or national media to promote the work of the club. Any photographs taken will be used solely for promotional purposes.
Date

MonthDayYear
Date
Parent's Signature

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