EYA Sports Club
EBCA
Participant Name
First Name
Last Name
Participant Age
Parent/ Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Relationship to participant
Phone Number
-
Area Code
Phone Number
Medical Insurance Provider:Please list your child’s current medical insurance provider (example: Kaiser Permanente, CalViva, Medi-Cal, etc.).
Does your child require medication during activities?
If yes, please explain:
EYA Sports Club involves physical activity and potential risk. I hereby release EYA Sports Club,EBCA, its staff, volunteers, and affiliates from any and all liability for injuries or damages that may occur during participation. I also grant permission for my child to participate in all program activities and for EYA Sports Club to use photos or videos of my child for promotional purposes.
Parent/ Guardian signature
Is the child in the after school program?
yes
no
How will they be getting home?
Walking
Picked up
Other
Submit
Should be Empty: