W.Y.B.S.A. 2009 SPRING
D REGISTRATION FORM
FOR BOYS BORN May 1, 1994 to April 30, 1996 (Age 13 and 14)
LAST NAME____________________________________ FIRST NAME_______________________________ BIRTH DATE_____/_____/_____ AGE NOW_______ TELEPHONE_______________________ CELL PHONE (_____) _______________________ ADDRESS__________________________________CITY_______________________ZIP___________
SHIRT SIZE (Circle one): Adult XXL Adult XLg Adult Lg Adult Med Adult Sm Youth Lg Youth Med Youth Sm
NOTE: ALL D KIDS REMAIN ON THE SAME D TEAM AS SUMMER 2008 UNLESS THE PARENT CHECKS HERE_____TO REQUEST A DIFFERENT TEAM/COACH. All 13 yr olds must be drafted, same with 1st yr D players.
Every team can use parents to volunteer in other areas as well. CIRCLE where you are able to help: MANAGER ASST MANAGER TEAM PARENT FUND RAISING TEAM SPONSOR Parent/Guardian GUARDIAN First Last Telephone Preferred E-Mail Address
__________________________________ ____________________ _______________________________
AUTHORIZATION FOR AGENT TO CONSENT FOR EMERGENCY TREATMENT: I / WE THE UNDERSIGNED PARENT OR LEGAL GUARDIAN OF THE ABOVE NAMED PLAYER, A MINOR, HEREBY AUTHORIZE W.Y.B.S.A. WADSWORTH, OHIO AS AGENTS FOR THE UNDERSIGNED TO CONSENT TO ANY MEDICAL EXAMINATION, X-RAY, ANESTHETIC, MEDICAL, OR SURGICAL TREATMENT AND CARE AT __________________________ HOSPITAL, WHICH IS DEEMED ADVISABLE BY, AND RENDERED UNDER, THE GENERAL OR SPECIFIC SUPERVISION OF ANY PHYSICIAN AND / OR SURGEON LICENSED BY THE STATE OF OHIO TO PRACTICE MEDICINE. WE THE UNDERSIGNED, PARENT (S), OR LEGAL GUARDIAN, REQUEST THE FOLLOWING:
TREATMENT / CARE RESTRICTIONS TO BE COMPLIED WITH: FAMILY PHYSICIAN____________________________________________ PHONE______________________ KNOWN ALLERGIES / SPECIAL CONDITIONS: ___________________________________________________________
MEDICATIONS__________________________________________________________________________
The risk of injury to participants is significant, including the potential for permanent disability and death. For myself, spouse and child I knowingly and freely assume all such risks, known and unknown, even if arising from negligence, and therefore hereby indemnify and hold harmless the W.Y.B.S.A., its officers, coaches, and directors for any and all liability incident to my or my child’s involvement in the program. I willingly agree to comply with the program’s stated and customary terms and conditions for participation, including all existing rules and WYBSA bylaws and those which may later be passed. If I observe or acquire any safety concern regarding the program or my child’s readiness for participation I will remove my child from the participation and bring such attention to the nearest coach or WYBSA official immediately. I am aware that the contact info for all officers and commissioners is posted at www.wybsa.info.
DATE _____________ LEGAL GUARDIAN__________________________________________ PHONE____________________ PAYMENT: ALL MAILED PAYMENTS WILL BE CONFIRMED BY E-MAIL OR CHECK THE WEBSITE AT WWW.WYBSA.INFO AFTER JAN 1, CLICK “PAID” TO SEE YOUR NAME. LEAGUE USE ONLY: AMT:
$75
PAID BY: CASH_____CHECK#__________SORRY, NO CREDIT CARDS.
LEAGUE__________ RECEIVED BY________ Payable to: WYBSA, mail to: 345 Brookpoint Cr, WADSWORTH, 44281