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Online Registration Form

The fee for Kickball registration is $85 ($80 registration fee + $5 PayPal surcharge). After submitting this form, you will be redirected to PayPal to submit your payment information. You may pay with a credit card (Visa, Mastercard, Discover or American Express), bank account or PayPal account.

Fields marked with an * are required.

 

KICKBALL

IN PER REGISTRATION AND TEAM SELECTION

SATURDAY, MARCH 10, 2012,

8AM @ ELIOT MIDDLE SCHOOL

2184 N. LAKE AVE. ALTADENA (LOWER FIELD)

 

General Information


League / Division*
Child's Name*
 

FIRST

MI

LAST
Address*
City*
Zip*
Date of Birth*
Age*
 
Experience / Measurements

Years of Experience*   Where?
Sex* M   F
Height*
Weight* LBS
Uniform Size*
Grade*
Name of School*
 
Parent's / Guardian's Information

Parent's / Guardian's Name*
Phone*
Cell Phone
E-mail Address*
 
Emergency Information

Emergency Contact*
Phone* (must be different than phone above)
Relationship*
Insurance / Medical Company
Policy Number
(for insured)
Policy Number
(for child)
Insured's Employer
Employer's Phone
Physician's Name
Physician's Phone
 

AUTHORIZATION FOR TREATMENT OF A MINOR
I, the undersigned, as parent/legal guardian of the above minor hereby authorize the BROTHERHOOD COMMUNITY YOUTH SPORTS LEAGUE or the delegated representative to consent to medical or dental treatment and/or hospital care to be rendered to said minor upon the advice of a licensed physician or dentist. This authorization is pursuant to the provisions of Section 25.8 of the Civil Code of California and California Practices Act. It is understood that if time and circumstances permit, the BROTHERHOOD COMMUNITY YOUTH SPORTS LEAGUE, will endeavor, but it is not required to communicate with me prior to such treatment.

I, the undersigned, further agree the Brotherhood Community and/or its designated representative(s) are not legally or financially liable for any claim arising from consent given in good faith in connection with such diagnosis or treatment advice.

This authorization and consent to treatment for the above mentioned minor is given in advance of need to the Brotherhood Community event, activity, or program in which my child is enrolled. This authorization shall remain effective as long as my child is enrolled in any Brotherhood Community event, activity or program, unless revoked sooner.

Parent / Guardian, please enter your name here if you agree*

 
Optional (for parents)

Would you like to volunteer?  Yes   No
Would you like to coach?  Yes   No
   
© 2012 Brotherhood Community Youth Sports  P.O. Box 94180, Pasadena, CA 91109  (626) 797-5673  bhcsports@sbcglobal.net