YOUTH SPORTS REGISTRATION

Participant Information

Participant Name*

First NameLast Name

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

School*

Grade*

Seasons in this sport:*

Seasons in other sports:*

Do you have medical Insurance?*

YesNo

Carrier:

Policy #

Doctors Name

Doctors Phone:

Parent/Guardian Information

Father/Guardian Email address:

Fathers Name

First NameLast Name

Fathers Number

Area CodePhone Number

Cell Number

Area CodePhone Number

Mother/Guardian Email address:

Mothers Name

First NameLast Name

Mothers Phone

Area CodePhone Number

Mother Cell

Area CodePhone Number

EMERGENCY AUTHORIZATION
If there is an emergency during participation in this program and I or another parent or guardian is not present, I authorize treatment and/or care at any hospital and I hereby authorize the volunteers and staff of this program as my agents. If I cannot be reached please contact the following person who is hereby authorized on my behalf:

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number*

Area CodePhone Number

Please list any medical condition(s), disabilities, present injuries, heart or respiratory illness or other conditions that may affect this child’s ability to participate:

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Any other information we should know.

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER:
To accept registration and permit participation in Knox County programs by the named participant, I the parent or guardian of said participant, hereby give my consent and agree to release, indemnify, and hold harmless Knox County, its officials, coaches, representatives and volunteers from any claim arising out of injury to the named participant. I acknowledge that Knox County does not provide medical insurance of any kind to participants.
For myself and on behalf of my heirs, assigns and next of kin, I acknowledge that participation in this program may include travel, participation on adverse field conditions, and risk of physical injury or death. For myself and on behalf of my heirs, assigns and next of kin, I willingly and voluntarily accept and assume all such risks of participation. I hereby release, discharge and agree to hold harmless Knox County, its employees, volunteers, officials, sponsors and other representatives from any and all claims, demands, costs, expenses and compensation arising out of or in any way related to any injury or other damage that may result to the participant while participating in this Knox County sponsored activity. I have read and agree to abide by the Knox County Sports Code of Conduct.
The below signed parent or legal guardian has read and understood the above information.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

Registration Fee*

USDRegistration

You will be directed to PayPal to make an online payment.

I am interested in volunteering for:

CoachAsst. CoachTeam ParentOther

For game cancellations call the Gameline at 215-GAME (4263) or follow us on Twitter at knoxcountyparks.

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Questions- Call 215-6600 Knox County policies and fees are subject to change

KNOX COUNTY PARKS AND RECREATION YOUTH SPORTS REGISTRATION