santa rosa hackers player registration
SANTA ROSA HACKERS PLAYER REGISTRATION PLAYER INFORMATION: Players Last Name:
First Name:
List Favorite Uniform Nos.
Middle Name:
1.
2.
Shirt Size:
Parent / Guardian Information:
Home Phone:
Birth Date: 3.
Shorts Size: Father _____
Mother _____
Other (Specify) ____________
Last Name:
First Name:
Email Address:
Work Phone:
Cell Phone:
Other Phone (Specify):
Parent / Guardian Information:
Father _____
Mother _____
Other (Specify) ____________
Last Name:
First Name:
Email Address:
Work Number:
Cell Number:
Other Phone (Specify):
Medical / Emergency Contact Information: List Any Medical Problems or Restrictions Player Has: Emergency Contact Name:
Relationship to Player:
Contact Phone:
Physician Name:
Medical Group Name (if Applicable):
Physician/Medical Group Phone:
Waiver Of Liability I, the Parent/Guardian of the Registrant, a Minor, agree that I and the Registrant will abide by the Rules of Santa Rosa Hackers, it’s affiliated Organizations and Sponsors, recognizing the possibility of physical injury related to Softball, and in consideration for Santa Rosa Hackers accepting the Registrant for its Softball Programs and activities (The “Programs”). I hereby release, discharge and/or otherwise indemnify Santa Rosa Hackers, its affiliated Organizations, Sponsors, their employees and associated personnel, including the Owners of Fields and Facilities utilized for the programs, against any claim by or on behalf of the Registrant as a result of the Registrant’s participation in the Programs and/or being transported to or from the Game, which transportation I hereby authorize. Parent or Guardian Name (Please Print)
Parent or Guardian Signature:
Date:
Consent for Medical Treatment As the Parent or legal Guardian of the above named Player, I hereby give consent for Emergency Medical Care prescribed by a duly licensed Doctor of Medicine or Doctor or Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb or well-being of my Dependent. Parent of Guardian Name (Please Print)
Parent of Guardian Signature:
Date:
First Name:
List Favorite Uniform Nos.
Middle Name:
1.
2.
Shirt Size:
Parent / Guardian Information:
Home Phone:
Birth Date: 3.
Shorts Size: Father _____
Mother _____
Other (Specify) ____________
Last Name:
First Name:
Email Address:
Work Phone:
Cell Phone:
Other Phone (Specify):
Parent / Guardian Information:
Father _____
Mother _____
Other (Specify) ____________
Last Name:
First Name:
Email Address:
Work Number:
Cell Number:
Other Phone (Specify):
Medical / Emergency Contact Information: List Any Medical Problems or Restrictions Player Has: Emergency Contact Name:
Relationship to Player:
Contact Phone:
Physician Name:
Medical Group Name (if Applicable):
Physician/Medical Group Phone:
Waiver Of Liability I, the Parent/Guardian of the Registrant, a Minor, agree that I and the Registrant will abide by the Rules of Santa Rosa Hackers, it’s affiliated Organizations and Sponsors, recognizing the possibility of physical injury related to Softball, and in consideration for Santa Rosa Hackers accepting the Registrant for its Softball Programs and activities (The “Programs”). I hereby release, discharge and/or otherwise indemnify Santa Rosa Hackers, its affiliated Organizations, Sponsors, their employees and associated personnel, including the Owners of Fields and Facilities utilized for the programs, against any claim by or on behalf of the Registrant as a result of the Registrant’s participation in the Programs and/or being transported to or from the Game, which transportation I hereby authorize. Parent or Guardian Name (Please Print)
Parent or Guardian Signature:
Date:
Consent for Medical Treatment As the Parent or legal Guardian of the above named Player, I hereby give consent for Emergency Medical Care prescribed by a duly licensed Doctor of Medicine or Doctor or Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb or well-being of my Dependent. Parent of Guardian Name (Please Print)
Parent of Guardian Signature:
Date:
