LGSL Paper Reg Form Spring 2012

							                                                LEESBURG GIRLS SOFTBALL LEAGUE
                                                  Spring 2012 REGISTRATION FORM
                                                                 DEADLINE: March 1, 2012

        EARLY REGISTRATION: $110 PER PLAYER / $90 EACH ADDITIONAL FAMILY MEMBER THRU JANUARY 8
      REGULAR REGISTRATION: $125 PER PLAYER / $105 EACH ADDITIONAL FAMILY MEMBER THRU FEBRUARY 17
  LATE REGISTRATION: $150 PER PLAYER / $130 EACH ADDITIONAL FAMILY MEMBER THRU MARCH 1 (WAIT LIST ONLY)


 MAIL COMPLETED FORM AND PAYMENT TO:
            LGSL
         C/O TREASURER
            P. O. BOX 1708
         LEESBURG, VA 20177


PLAYER INFORMATION:              (NEW PLAYERS MUST SUBMIT A COPY OF BIRTH CERTIFICATE)

NAME:__________________________________                D.O.B. _________________AGE        (AS OF 12/31/10)_____________

ADDRESS:________________________________CITY:_________________________ZIP:___________

HOME PHONE:__________________________ FAMILY EMAILS:__________________________________________

SCHOOL CURRENTLY ATTENDING:_____________________________________________GRADE:______________

DIVISION:     PLEASE CHECK DIVISION PLAYER WISHES TO PLAY IN:

 (FOR DETAILS ON AGE DIVISION ELIGIBILITY OR TO REGISTER ONLINE, PLEASE VISIT OUR WEB SITE WWW.LEESBURGGIRLSSOFTBALL.ORG)

________4U TINY T-BALL           ________ 6U T-BALL        ________ 8U MACHINE PITCH

________INSTRUCTIONAL 10U: PLAYER/MACHINE PITCH                      ________ ADVANCED 10U: ALL PLAYER PITCH

________12U PLAYER PITCH            _______14U: PLAYER PITCH           ________16/18U: PLAYER PITCH


REVOLUTION:        10U       12U       14U      16U        18U


SOFTBALL EXPERIENCE: (NUMBER OF SEASONS):_______________________________________

LAST SEASON’S COACH / TEAM:____________________________________________________

SPECIAL REQUESTS (NOT GUARANTEED) ____________________________________________

UNIFORM INFORMATION:

T-SHIRT SIZE:      YOUTH:    S    M    L   XL ADULT:   S    M    L    XL

SHORTS SIZE:       YOUTH:    S     M   L   XL ADULT:   S    M    L    XL

SOCKS SIZE:     YOUTH        ADULT
PARENT/GUARDIAN EMERGENCY INFORMATION:

MOTHER’S NAME___________________________________ WORK #____________________ CELL#_________________________

FATHER’S NAME ___________________________________ WORK #____________________ CELL#_________________________

INSURANCE CO.____________________________________POLICY/ID#________________________________________________

EMERGENCY CONTACT_________________________________________________________PHONE_________________________

PLEASE INDICATE ANY MEDICAL CONDITION THAT YOUR CHILD’S COACH SHOULD BE AWARE
OF:______________________________________________________________________________________________________



LIABILITY RELEASE STATEMENT:

I DO HEREBY GRANT PERMISSION FOR THE ABOVE NAMED YOUTH TO PARTICIPATE IN ALL ACTIVITIES INVOLVED WITH THIS SPORTS
PROGRAM. I ASSUME ALL RISKS AND HAZARDS INCIDENTAL TO SUCH PARTICIPATION INCLUDING TRANSPORTATION TO AND
FROM SAID ACTIVITIES AND DO HEREBY RELEASE AND WAIVE AND ALL CLAIMS OR ACTIONS FOR DAMAGE OR INJURY OF ANY KIND
AGAINST LEESBURG GIRLS SOFTBALL LEAGUE, THEIR VOLUNTEERS AND/OR OTHER PARTICIPANTS ARISING FROM ANY ACTIVITIES
RELATED TO THIS SPORTS PROGRAM. I FURTHER HEREBY GRANT PERMISSION FOR EMERGENCY FIRST-AID TO BE GIVEN TO THIS
MINOR AND FOR HER TO BE TAKEN TO THE EMERGENCY ROOM OF A NEARBY HOSPITAL IN THE EVENT OF A SERIOUS INJURY.
PERMISSION IS HEREBY GRANTED TO THE HOSPITAL AND STAFF TO PROVIDE ANY TREATMENT THAT A PHYSICIAN DEEMS
NECESSARY FOR THE WELL-BEING OF THE YOUTH.




__________________________________________________________________                  ___________________

SIGNATURE OF PARENT/GUARDIAN                                                        DATE


VOLUNTEER OPPORTUNITIES: CIRCLE ANY THAT ARE OF INTEREST. FOR POSITIONS OTHER THAN COACHING, A BOARD
MEMBER WILL CONTACT YOU WITH MORE INFORMTION..

HEAD COACH    ASSISTANT COACH       CONCESSIONS OPENER/CLOSER    CONCESSION SALES

SPONSOR      TEAM PARENT       UMPIRE   SCOREKEEPER    TOURNAMENTS      CARNIVAL

OTHER SPECIAL EVENTS (PLEASE SPECIFY)______________________________



FOR MORE INFORMATION PLEASE VISIT OUR WEB SITE AT WWW.LEESBURGGIRLSSOFTBALL.ORG




FOR LEAGUE USE ONLY:

DATE RECEIVED: __________________AMOUNT PAID: _________________________CASH/CHECK#:_______________

DESCRIPTION OF PAYMENT:_________________________________________________________