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12210 BUSHEY DRIVE - MONTGOMERY COUNTY DEPARTMENT OF RECREATION

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12210 BUSHEY DRIVE - MONTGOMERY COUNTY DEPARTMENT OF RECREATION Powered By Docstoc
					          MONTGOMERY COUNTY DEPARTMENT OF RECREATION – 4010 Randolph Road, Sports, SILVER SPRING, MARYLAND 20902
                                        Main (240) 777-6961, FAX: (240) 777-6915

        Please return to the Sports Office Attn: Angie Walker                              The participant assumes all risks associated with participation in the program; the County
                                                                                           assumes no liability for injury or damages arising from participation in the program. Due to
        TEAM ROSTER                                                                        the strenuous nature of some activities, the County encourages each participant to consult his
       YEAR: 2009             SPORT:     T-Ball                                            or her physician concerning fitness to participate in the program. The participant consents to
                                                                                           emergency treatment. The participant also consents to the County’s use if any photographs
                                                                                           taken or video tapes made of the program. If the participant is a minor, the parent or guardian
        Grade: _________________                                                           approves his or her participation in the program.

     TEAM NAME                                                            Coach’s NAME: ________________________________
     ADDRESS:
     CITY _                                                         ZIP _______________
      PHONE: H:                        _________________           __W:                    FAX #:          ________
     E-MAIL ADDRESS:                                     ______________________________

Name (please print legibly)                STREET ADDRESS                           CITY                    SCHOOL                  ZIP       GRADE HOME PHONE WORK PHONE

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