MCAA BASEBALL SOFTBALL UMPIRE REGISTRATION FORM by ffq12461

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        MCAA BASEBALL & SOFTBALL UMPIRE REGISTRATION FORM
                                           Please print clearly and complete all questions below.

                                                                       PARTICIPANT INFORMATION 
                                                                                          
                          Last Name:                                                               First Name:                                           
                           
                          (Circle One):    Male     Female              DOB:  ____/_____/_________            Age:                 Grade:      
                           
                          Street Address:                                                                City/Town:                                      
                           
                          Mailing Address (if different):                                                                                                
                           
                          Home Phone #:                                                   Cell/Alt. Phone #:                                             
                           
                          E‐Mail Address:                                                                                                                
                           
                          NBRL Baseball U#:                                      NBRL Softball U#:                         
                           
                          Years of umpiring experience: _______        Is this your first time umpiring for MCAA? (Y/N): ________ 
                           
                                                       PARENT/GUARDIAN INFORMATION
                                                 (If you are under the age of 18 this section must be completed)
                           
                           
                          Mother/         Last Name:                                         First Name:
                          Guardian #1
                                              Cell Phone #:                                            E-mail:
                                              Complete the following only if different then above:
                          Address
                                              Street:                                                  City/Town:
                                              Home Phone #:
                          Father/
                          Guardian #2         Last Name:                                               First Name:
 
                                              Cell Phone #:                                            E-mail:
                                              Complete the following only if different then above:
                          Address
                                              Street:                                                  City/Town:

                                              Home Phone #:
 
 
                                                                   MEDICAL/LIABILITY RELEASE
 
                           I, the parent/guardian of the registrant, a minor, agree that I, and the registrant will abide by the rules of MCAA. I also
                              recognize the possibility of physical injury associated with sports, specifically umpiring, and in consideration of the
MCAA USE ONLY 
                          MCAA accepting registrations for its sports programs/activities. I hereby release, discharge, and otherwise indemnify the
 
                          MCAA and its affiliated organizations and sponsors, their employees and volunteers including the owners of fields and
                               facilities utilized for the programs, against any claims by or on behalf of the registrant as a result of the registrant’s
W9 Tax Form                    participation in the programs and/or being transported to or from same, which transportation I hereby authorize.
 
Patched – BB              Please list any known medical/allergies problems:
 
Patched – SB           
 
                          In case of emergency, notify: (other than above)                                               Phone #:
Attend Clinic             Family Physician:                                                        Physician Phone #:
 
                          Consent for Medical Treatment:
                          As the parent or legal guardian for the above named player, I hereby give my consent for emergency medical care
                          prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever
                          conditions are necessary to preserve the life, limb, or well being of my dependent.

 
                          Parent/Guardian Name (Please Print)                 Parent/Guardian Signature                             Date

								
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