Taylor County Recreation Registration Form
Baseball / Softball 2011
(First Name)_______________________ (Middle)__________________________= _ (Last) _______________________________
DOB: _______________ Gender: ____________
Address (E911) _________________________________ City: ____________________ State: ______ ZIP Code: _____________
Father’s Name: _________________________________= __ Phone: _________________ Email Address: ___________________
Mother’s Name: _________________________________= _ Phone: _________________ Email Address: ___________________
Child’s Physical Condition: _________________=
___________________________________________________________________
(List any physical or mental handicaps or diseases suc= h as epilepsy, heart murmur, rheumatic fever, etc. which your child may have or = any other special medical information which may affect your child’s participation).
Health Insurance:&nbs= p; YES or NO = Name of Insurance: ______________________________________
Uniform size: Shirt: _______________________ =
Shorts:
__________________________
Participation fee for the 2011 season is $45.00 this includes the cost of uniforms= . A service charge of $40.00 will be charged for all returned checks.
Birth Certificate =
must be
provided at the time of registration.
I/We, the parent(s) of the above named child, do hereby certify to the Taylor Cou= nty Recreation Board that my/our child is physically and emotionally fit= to participate in the activity set forth above. I/We understand that participation requires practice, conditioning, and perseverance. Specifically, I/We recognize= that participation in such activity requires physical and mental endurance, and = that participation in the activity will require exertion on behalf of my/our chi= ld, and that such exertion includes, but is not limited to, cardiovascular and muscular exertion and effort.
I/We acknowledge that the= Taylor County Recreation Board has not made, and cannot make, any determination th= at my/our child is medically fit to participate as set forth herein. The Taylor County Recreation= Board recommends that any child participating in the activity set forth above rec= eive a complete physical examination by a physician.
I/We acknowledge that I/W= e have provided the Taylor County Recreation Board with any special medical information which may affect my/our child’s participation.
I/We, the parent(s) of th= e above named child, hereby give my/our approval for his/her participation in activities during the current season. I/We assume all risks and hazards incidental to the conduct of the activities as well as transportation to and from activities. I/We do further hereby release, ab= solve, indemnify and hold harmless the Taylor County Recreation Board, the organiz= ers of the activity, sponsors, and supervisors from any and all claim or claims= , of any nature whatsoever, whether at law or in equity, arising out of or in any way related to the activity set forth herein.
I/We, the parents of the = above named child, hereby give my/our permission to the person in charge of the a= ctivity to take my/our child to the doctor or hospital in case of injury. I/We understand I/We will be respo= nsible for any and all cost incurred by emergency transportation or medical treatm= ent provided.
PARENT’S&nbs= p; SIGNATURE: _____________________________________________ Date: _________________________________
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