DWIGHT YOUTH SOFTBALL REGISTRATION FORM AND by 4w269Or

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									                    DWIGHT YOUTH SOFTBALL REGISTRATION FORM
                            & AUTHORIZATION CONSENT TO MEDICAL TREATMENT
                                          FOR A MINOR CHILD



_____ First Year Child                                               Last Year’s Team ________________________


Child’s Name ___________________________                             Jersey Size _____________________________
                                                                                          st
Birth Date ______________________________                            Age as of Sept 1 ________________________
Address_______________________________                               Jersey # request ________________________
                                                                                  nd
City _________________ Zip Code _________                            Jersey # 2        choice _______________________
Phone # _____________________________                                Current Grade ___________________________
Email: ______________________________                                Cell or work phone ________________________
Parent’s or Guardian’s Name _______________________________________________
Parent/Guardian’s Address & Phone (if other than above) ______________________________________
Child’s Doctor_________________________                              Dr’s Phone # ___________________________
Hospital Preference _____________________                            EMERGENCY phone # ____________________
Does child take medication? ________No ________Yes                    Please List Drugs (if yes) _________________


       I (We) authorize my (our) child to participate in Dwight Youth Softball Program. I (We) also authorize my (our)
       child’s Dwight Youth Softball League coach or League office to consent to any x-ray, examination, anesthetic,
       medical or surgical diagnosis, or treatment and hospital care to be rendered to the minor under general or special
       supervision and on the advice of any physician or surgeon licensed to practice in the State of Illinois when the need for
       such treatment is immediate and when efforts to contact me (us) is unsuccessful.
       I (We) agree to be responsible for any medical costs not covered by insurance.
                                                                 Dated this ______ day of ____________________, 20 ___.


***Signature of PARENT or GUARDIAN ___________________________________________________

Adult volunteers are needed; I would be willing to help with: (Please circle all that apply)

       Coaching,        Asst Coaching,            Chairperson,            Other
**********************************************************FOR****LEAGUE***USE*****ONLY*******************************************

        ABSOLUTELY NO LATE SIGN UPS AFTER MARCH 21st

       TOTAL PAID:______________                                 circle one     Cash or Check:               ck#_________
       FEES:                                                                                   LATE FEES AFTER 2/21/11:
      Minors & Majors            $30.00                                                        Minors & Majors         $45.00
      Juniors & Seniors $40.00                                                                 Juniors & Seniors       $55.00
                                 Max fee of 85$ to families of three or more girls in program

								
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