You are on page 1of 1

Mid Valley Baseball Registration Form Spring 2013 PO BOX 16338, Encino, CA 91416

PLAYER INFORMATION: First Name: Last Name: School No Banner Birth Date: Postcard Website If no, previous league: Other

How did you hear about us: (circle one) Returning Player: (circle one) Yes

Age of child as of April 30, 2013 is DIVISION PLAYING AGE: T-Ball (Ages 3-4) 5/01/08-4/30/10 Shetland (Age 5-6) Pinto (Ages 7-8) 5/01/06-4/30/08 5/01/04 4/30/06 YXS YS YM YL Mustang ( 9-10) 5/01/02-4/30/04 YXL AS AM Bronco (11-12) 5/01/00-4/30/02 AL AXL Pony (Ages 13-14) 5/01/98-4/30/00

T-shirt/Jersey Size: (circle one) Street Address: Home Phone: ( )

City: Mothers Cell Phone: (

Zip: Fathers Cell Phone: (

EMAIL ADDRESS(ES): School: Fathers Name: Mothers Name: Child Resides With: Both Parents/Mother/Father/Other Fathers Employer: Mothers Employer:

I/we recognize that there are potential hazards on the field including, but not limited to, the risk of being injured or having property damaged by baseballs or bats, and general actions by spectators, players, and others in attendance. I assume all risk of such injury and property damage incidental to such participation, including transportation to and from the activities; and I agree that Mid Valley Youth Baseball and any of its sponsors, representatives, and affiliates are not liable for injuries or damages resulting from such causes. AUTHORIZATION TO TREAT MINOR: I/we the undersigned parent(s) or legal guardian of the above said child, a minor, do herby authorize and consent to any X-ray examination, anesthetic medical or surgical treatment rendered by any member of the medical or emergency room staff licensed under the provisions of the Medical Practice Act; or a dentist licensed under the provisions of the Dental Practice Act and on the staff or any acute general hospital holding a current license to operate a hospital from the State of California, Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care deemed advisable by the physician rendering treatment to the patient, but that none of the above treatment(s) will be withheld if the undersigned cannot be reached. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

Please list any medications your child is taking and/or disabilities your child may have: THIS CONSENT WILL REMAIN IN EFFECT UNTIL June 1, 2013
I have read the rules and agree! (initial here)

I/We will abide by the rules of Pony Baseball and Mid Valley Youth Baseball. I/We will act in a sportsmanlike manner at all times at the fields. I/We understand that alcoholic beverages are strictly prohibited AT ALL TIMES on the premises and that violators will be cited. No refunds will be made unless physically unable to participate. Lack of desire will not result in a refund. I/We understand no pets/animals are allowed on premises. I/We give permission to the league to use and publish photographs or video recordings of my child for website stories, newspaper articles, marketing and publicity purposes. Mid Valley Baseball agrees to use all published pictures and video recordings for appropriate use and will remove any pictures from the website or prior to print media publishing, at the parents/guardians said request.

EACH TEAM IS RESPONSIBLE FOR A $200 TEAM SPONSOR, AS WELL AS OTHER CONTRIBUTIONS FOR OPTIONAL JERSEY LETTERING AND COACHS GIFTS, AND WHATEVER ELSE IS NEEDED AS DECIDED BY MANAGER AND TEAM MOM. Signature of Parent or Legal Guardian: Print Name: Date:

SPRING 2013 REGISTRATION FEES: Registration fee includes jersey and hat, picture package, participation award and $50 fundraising. T-Ball - $175 Shetland - $195 Pinto - $275 Mustang - $275 Bronco - $275 Pony - $300 $50 non-refundable payment is collected with registration fee at the time of registration to fulfill mandatory fundraising obligation. There will be a $30 fee for all returned checks!
LEAGUE USE ONLY: Registration: Cash / Check: Date: By: