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REGISTRATION: NOW - OCT. 18 GAMES WILL BE PLAYED WEEKDAY AFTERNOONS For Children 3rd-12th Grade Cost: $40.00 members; $50.00 DOD-members

Sibling discount $5.00; Late Registration Fee $10.00

Player's Last Name Address Birthdate ___j __ Grade Name of Parents/Guardians: Mother Father Other Emergency Contact
Ages: 03-405-6 Shirt Size (circle
one):

First Name (goes by) City

/ __

Phone Zip _

Age

o Male 0 o Non-Member

Female

o Member
Work # Work #

Cell # Cell #

Email Email Work # Cell #

Home#
07-8 09-10011-13014-17

0 YS 0 YM 0 YL 0 AS 0 AM 0 AL 0 AXL

All games will be played at the YMCA.

I certify that this child is in normal health and capable of participating in the YMCA youth athletics. I do acknowledge the risk of injury is possible. I grant permission for my child to play and in dOing so I hereby release any and all rights and claims for injuries and damages I may have againsllile YMCA their Board. Managers. Employees. Officials. Volunteers and Coaches. If medical attention is required. I give my permission for such medical care when either I or the emergency contact person cannot be notified. I understand that the YMCA does not cany accident insurance on league participants. I agree that the YMCA may photo or videotape my child and use It for their promotion. Parents are responsible for providing transportation Name of insurance company If your child has any Allergies. Asthmatic conditions, or any hindrances for their child to and from practice sessons and games. Insurance poliCY number that may affect your child's ability that the Branch should be aware of please list. _

IN WITNESS WHEREOF.

I have executed this Registration. this the day of

WaiveriRelease

and Medical Certification (month)

form With full knowledge of its contents on (year). Print ParenVGuardian Name

ParenVGuardian Signature

We hope you are willing to volunteer in support of this sport program. Please check one (1) or more of the following areas to participate ill: o Coach 0 Assistant Coach 0 RefereelUmpire
FOR OFFICE USE ONLY:
Date Registered Am!. Paid Registered

By