WORTHINGTON PARKS AND RECREATION DEPARTMENT

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					Please list ONE other player your child would like to play with:

________________________________________
(Do not list coaches as they have yet to be determined.)
(This is a request and is not guaranteed.)

              GIRLS SUMMER SOFTBALL INFORMATION SHEET
                          WORTHINGTON PARKS AND RECREATION DEPARTMENT

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PLAYERS NAME:___________________________________ PHONE:___________________________


DATE OF BIRTH:____________________AGE__________

GRADE COMPLETING THIS YEAR:_______ SCHOOL ATTENDING:___________________________
Players will be primarily placed on teams with girls from the school they attend. If you would like your
child to play with girls from a neighborhood school that they don’t attend, please indicate it on the above
line.

PARENT NAMES:___________________________________________________________

EMAIL:____________________________________( Coaches may email you regarding practices and games.)

PHONE:(Home)________________ (Work)__________________ (Cell)________________

Did you play here in 2007?     YES     NO             If yes, who was your coach:_______________________

Have you previously played softball?       YES      NO

Are you presently playing school softball?     YES            NO

Do you plan to play travel, or select Softball this summer? YES              NO

How many years have you played softball _____________________

What positions have you or do you play? (PLEASE CIRCLE)
1st Base 2nd Base 3rd Base Outfield        Pitcher                    Catcher                    Shortstop

Does either parent have interest in coaching? (Please Circle)    YES              NO           HEAD     ASSISTANT

If interested in coaching please fill out a coaches application located at the control desk.

SHIRT SIZE: YM         YL      AS      AM        AL        AXL                AXXL

  NOTE: If you are uncertain of size, you may want to order one size larger. Reorders will be at your OWN
EXPENSE !
                      Worthington Parks and Recreation Programs
                           EMERGENCY MEDICAL AUTHORIZATION
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Participants' Name___________________________________________________
Address________________________________________________________________________________
                                                                     City                            Zip
Phone number_____________________ Birth date_________________________

PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for children who
become ill or injured while participating in a Worthington Parks & Recreation Department program, when parents
or guardians cannot be reached.
               Part I - To Grant Consent
In the event reasonable attempts to contact _________________________________________________
at (phone number)___________ or (other parent or guardian) ________________________ at (phone
number)_______________, or (other relative or child care provider)__________________________ at
(address)_______________________________________________________and (phone number)
_________________, who is the child's (relationship) ______________________ have been unsuccessful, I
hereby give consent for: 1) the administration of any treatment deemed necessary by:
Dr.(preferred physician) _______________________________at (phone number) ____________________ or
Dr. (preferred dentist) ______________________ at (phone number) ___________________ or Dr.(preferred
medical specialist) ______________________________at (phone number) _______________ or, in the event the
designated preferred practitioner(s) are not available, by another licensed physician or dentist and 2) the transfer of
the child to (preferred hospital) __________________________________or any hospital reasonably accessible.
 This authorization does not cover major surgery unless the medical opinions of two licensed physicians or
dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Facts concerning the child's medical history including allergies, medications being taken and any physical
impairments to which a physician should be alerted:_______________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

____________________________________________ Date _________________
Signature (Parent or Legal Guardian)
Address____________________________________________________________
            Part II - Refusal to Consent
      (DO NOT Complete Part II if You Completed Part I)
I do NOT give my consent for emergency medical treatment of my child. In the event of an illness or injury
requiring emergency treatment, I wish the Parks & Recreation authorities to take the following actions:
___________________________________________________________________
___________________________________________________________________

____________________________________________Date __________________

Signature (Parent or Legal Guardian)

				
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