THOMASTON-UPSON COUNTY RECREATION & PARKS DEPARTMENT

                    YOUTH PARTICIPANT REGISTRATION FORM

                                                      Basketball                    

 

 

Name _______________________________  Mailing Address _____________________________

 

City _____________________    Inside ____   Outside ____  City Limits

 

Phone ___________________   Date of Birth __________________    Age __________________

 

Male _____  Female _____ Grade _______  School ______________________________________

 

Team Played on Last Year __________________________________________________________ 

 

Parent's Name ___________________________   Email Address ___________________________

 

Business Phone   Father __________________________      Mother _________________________

 

Home Phone  Father __________________________    Mother _____________________________ 

 

Doctor ______________________________________  Phone  _____________________________

 

Child's Physical Condition _____________________________________________________  

 

(List any physical or mental handicaps or diseases such as epilepsy, heart murmur, rheumatic fever, etc. which your child may

 have or any other special medical information which may affect your child's participation).

 

All Participants please select shirt size:

Please select SHIRT SIZE:     YS   YM   YL       AS   AM   AL   AXL   A2X

 

*************************************************************************

The Thomaston-Upson Recreation Department would like to notify parents/guardians that photos of individual players or teams

will be taken for our sponsors and promotional projects.

 

I/We, the above parents of the above named child, hereby give my/our approval for their participation in activities during the

current season.  I/We assume all risks and hazards incidental to the conduct of the activities and transportation to and

from activities.  I/We do further hereby release, absolve, indemnify and hold harmless the Thomaston-Upson County

Recreation Commission, Recreation & Parks Department, the organizers of the activity, sponsors, supervisors any or all

of them.  In case of injury to my/our child, I/We hereby waive all claims against the organizers, the sponsors, or any of

the supervisors appointed by them except to the extent covered by insurance.  I/We do certify that our ward is covered

by group accident or other comparable insurance.

 

I/We, the parents of the above named child, hereby give my/our permission to the person in charge of the activity to take

my/our child to the doctor or hospital in case of injury.  I/We understand I/We will be responsible for any and all cost

incurred by emergency transportation or medical treatment provided.

PARENT'S SIGNATURE                                                        DATE                     RECEIPT NO.  _________________________