Youth Baseball Registration Form - Conway Parks, Recreation ...

Conway Parks, Recreation & TourismYouth Baseball Registration Form2011Child’s Name (First, Middle, Last) _______________________________________________________________________Age __________ Sex: (Please circle) M F Date of Birth__________________________Address_______________________________________City__________________________Zipcode________________Home Phone________________________________ *Email ___________________________________________Parent/Guardian _______________________________ Relationship __________________ *cell #______________________Parent/Guardian _______________________________ Relationship __________________ *cell #______________________Is there a sibling playing in the same league?__________ Name _____________________________________ Age ________I live in the City Limits of Conway: YES NOYESNO I would like to receive email and/or cell phone text updates on events, activities and/or cancellations. Phone charges may apply.(Please check one):(The child’s age on May 1 determines the league you will play in.)T-Ball (5/6) Pitching Machine (7/8) Dixie Minors (9/10) Dixie Youth (11/12) Dixie Boys (13/14)SHIRT SIZE Shirts are ordered based on the size you specify. You will be billed the replacement cost if you order the wrong size shirt.(please circle one) Youth S M L Adult S M L XLARE YOU INTERESTED IN COACHING?YES NO Head Coach Assistant CoachVisit us online at www.ConwayParksandRecreation.comfor more information on being a youth sport coach!INSURANCE YES - I would like to purchase Recreation Accident Insurance for my child. Cost is $10.00.NO – I am not interested in purchasing this insurance. I waive my right to purchase this insurance.PARTICIPATION RELEASE- I give permission for my child to participate in this activity organized by Conway Parks and Recreation. CONSENT TOTREATMENT- If my child requires medical treatment or medication while participating, I give my permission for Conway Parks & Recreation/EMS toprovide the appropriate treatment. INSURANCE RELEASE- I understand that insurance is offered at the time of registration for a nominal fee. Iunderstand that if I waive the right to purchase insurance, I release the City of Conway from any and all liabilities and claims as a result of anyaccidents that may occur. GENERAL RELEASE – I agree to hold harmless the City of Conway, its departments, agents, employees, officials andvolunteers for any injury, illness or damage to person or property during the course of this organized activity. I also waive, to the extent not coveredby liability insurance, any claim against any person transporting my child to or from activities. I am a parent/guardian of this child. I have read andfully understand these releases. I agree to return all equipment loaned that my child may use or be responsible for the replacement costs. Ihave received, read, and agree to the commitment, rules, regulations, and guidelines set forth in the "Parent Code of Conduct". I furtherunderstand that once my child is placed on a team, no refunds will be issued.__________________________________________________ _______________________________________________ __________________Printed Parent Name (Legal Guardian) Parent Signature (Legal Guardian) DateFOR OFFICE USE ONLYBirth Certificate On File YES / NOLEAGUE __________________TEAM _______________________________________________Signed Code of Conduct Received VERIFIED BYSport Information Sheet givenRegistration Date _________________Registration Fee $21.00 / $41.00Insurance Fee __________________Discounts __________________Total Paid __________________Cash Check# CC