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MADISONVILLE YOUTH BOOSTER SPORTS REGISTRATION

PLEASE PRINT AND FILL OUT FORM IN FULL.
PROGRAM (CIRCLE ONE): T-BALL BASEBALL FOOTBALL SOFTBALL CHEER BASKETBALL SOCCER

ATHLETES NAME (PLEASE PRINT NAME EXACTLY AS IT APPEARS ON BIRTH CERTIFICATE): _________________________________________________________________________________________________________ BIRTH DATE: ____________________ AGE: ____________________

M SEX: ____________________

PHYSICAL ADDRESS: ____________________________________________________________________________________ STREET CITY STATE ZIP HOME PHONE #: ______________________________ EMAILADDRESS: _____________________________ FATHER NAME: ______________________________ STEPFATHER NAME: _________________________ EMERGENCY PHONE #: ______________________________ WHOM DOES THE CHILD RESIDE: ____________________ MOTHER NAME: ____________________________________ STEPMOTHER NAME: _______________________________ NO: ____________________

ANY MEDICAL PROBLEMS OR LIMITATIONS? *YES: ____________________

*IF YES, PLEASE EXPLAIN: _______________________________________________________________________ SHIRT SIZE (CIRCLE ONE): YOUTH: SMALL MEDIUM LARGE ADULT: SMALL ADULT: SMALL MEDUIM MEDUIM LARGE LARGE EXTRA LARGE EXTRA LARGE

SHORT OR PANT SIZE (CIRCLE ONE): YOUTH: SMALL MEDIUM LARGE

WE WELCOME AND ENCOURAGE PARENTAL PARTICIPATION TO ENHANCE THE QUALITY OF YOUR CHILDS EXPERIENCE IN MADISONVILLE YOUTH BOOSTER PROGRAM. PLEASE INDICATE BELOW IN WHICH OF THE FOLLOWING AREAS YOU WOULD BE ABLE TO CONSTRIBUTE YOUR TIME:

SPONSOR: _____

COACH: _____

ASST. COACH: _____

GATE/CONCESSIONS: _____

I GIVE MY SON/DAUGHTER PERMISSION TO PARTICIPATE IN THE MADISONVILLE YOUTH BOOSTERS SPORTS PROGRAM. I UNDERSTAND HE/SHE WILL BE COVERED BY A SECONDARY INSURANCE POLICY MANDATORY THROUGH THE LEAGUE. I, THE UNDERSIGNED, PARENT OR GUARDIAN OF THE HEREIN REGISTERED CHILD DO HOLD HARMLESS THE MADISONVILLE YOUTH BOOSTERS ORGANIZATION, THE TOWN OF MADISONVILLE, RECREATION DISTRICT #14, OWNERS OF THE PROPERTY USED FOR RECREATIONAL SPORTS, ITS OFFICERS, DIRECTORS, COACHES, REFEREES AND OTHER APPOINTED BY OR ACTING FOR SUCH ORGANIZATION, FOR ANY INJURIES SUSTAINED BY THE HEREIN REGISTERED CHILD AS A RESULT OF ANY PRACTICE, COMPETITION, OR TRAVEL TO AND FROM SUCH PRACTICES OR COMPETITION, HURT OR DAMAGE SUSTAINED BY THE REGISTERED ATHLETE AS A RESULT OF HIS/HER PARTICIPATION IN THE TOWN OF MADISONVILLE. I ALSO UNDERSTAND THAT ANY FALSE OR INACCURATE INFORMATION COULD JEOPARDIZE NOT ONLY MY CHILDS PLAYING STATUS BUT ALSO THAT OF THE TEAM INVOLVED. IN THE EVENT OF AN ACCIDENT OR INJURY TO MY CHILD, I GIVE PERMISSION TO THE MADISONVILLE YOUTH BOOSTERS STAFF OR ANY OF ITS COACHES TO SEEK MEDICAL EMERGENCY TREATMENT FOR MY CHILD AT THE EMERGENCY ROOM OF ANY MAJOR HOSPITAL. I UNDERSTAND THE NEED FOR ME TO TAKE AN ACTIVE ROLE AND VOLUNTEER MY TIME.

SIGNED: _________________________________________________________ PARENT OR GUARDIAN* (WHOEVER SIGNS IS MYB MEMBER)

DATE: __________________________

ADDITIONAL MYB MEMBERSHIP NAME: ________________________________________________________________ OFFICIAL USE ONLY COST VERIFICATION REGISTRATION FEE: $_________ (CHECK ONCE VERIFIED) OUT OF DISTRICT FEE ($50.00/FAMILY/SPORT) $_________ BIRTH CERTIFICATE: __________ MYB MEMBERSHIP FEE* ($5.00): $_________ PROOF OF RESIDENCY: __________ ADDITIONAL MYB MEMBERSHIP FEE ($5.00): $_________ $_________ MULTIPLE CHILDREN REGISTERED 2ND CHILD DISCOUNT (-$5.00): TOTAL PAID: $_________ CIRCLE ONE: CASH CHECK/#_________