Parental Consent Release Form by lhs69096


More Info
									                                                                           Mascoutah Khoury League
                                                            (An Affiliate of George Khoury Association of Baseball Leagues, Inc.)
                                                                                   P.O. Box 50
                                                                              Mascoutah, Illinois 62258

              Player Information: (please print)                                                                                                           FEES
                                                                                                                                 T-Ball: $40.00 per player      Softball: $75.00 per player
Last Name: __________________________ First Name: ________________________                                        Baseball: Atom 1 - Juvenile 1: $75.00 per player        Seniors: $100.00 per player
Street Address: _________________________________________________________                                                           ($10 discount for each additional player in family)
City: _______________________________ State: _______ Zip: ________________                                                 (Financial assistance available. Ask at registration or call 566-7274)
Date of Birth: _____/_____/_____           Male _____    Female _____                                                                          Volunteer Fee: $25.00 per family
Eyes: __________        Hair: ____________    School: _____________________

Parent or Guardian:                                                                                                                      PARENTAL CONSENT TO PLAY
Last Name: __________________________ First Name: ________________________                         I, the undersigned parent or legal guardian of ___________________________________________,
Street Address: ______________________________________________________                                                                                                            (players name)
City: _______________________________ State: _______ Zip: ________________                         do, hereby, consent and agree that the above named minor may participate in the George Khoury
Home Phone: _____________________ Second Phone: ________________________                           Association of Baseball Leagues, Inc. (hereafter referred to as the Association) and Mascoutah
E-mail Address: _________________________________________________________                          Khoury League, Inc. It is agreed that the named association or sponsor assumes no legal liability for
                                                                                                   injuries or other loss as a result of such participation. It is further agreed that this consent shall
Does your child have a medical condition?      Yes ____      No ___                                remain in full force and effect until such time as the undersigned parent or legal guardian shall notify
(If yes, please provide medical release form from doctor)                                          the Association and Mascoutah Khoury League, Inc. in writing of the abrogation or cancellation of
                                                                                                   this consent. This registration is subject to all provisions of the Khoury League Rule Book. By your
Did you play on any Khoury League Team last year?                                                  signature below, you acknowledge that you are familiar with all provisions of said official rule book,
Coaches Name: ________________________ Age Bracket: _____________________                          and that in consideration of participation in the Association you or your agents will not contest any
Khoury Organization: _____________________________________                                         of its provisions.

                           Shirt Size                                                                                                                 Date:
                                                                                                   Signature: ___________________________________________ _____________________
        Youth                                Adult                                                                      (Parent or Guardian)
        S M L                             S M L XL XXL
                                                                                                   Parent Interested in:          Mgr.          Coach        Helping        Coach Shirt Size: _______

To top