INDIVIDUAL PLAYER REGISTRATION FORM ___________________________________________ ______________________________________ ________________ _____________________________ FIRST NAME LAST NAME SEX SHIRT SIZE ADDRESS ______________________________________________ ________________________________________________ HOME PHONE DAY PHONE OCCUPATION _____________________________________________________________ ___________________________________________________________________ EMAIL DRIVERS LICENSE # I, THE ABOVE NAMED PLAYER, CERTIFY THAT I AM NOW
YEARS OLD.
DATE OF BIRTH. __________________
THIS RELEASE FORM MUST BE SIGNED BY THE PARTICIPANT AND RETURNED TO THE YOUNGSVILLE
SPORTS COMPLEX OFFICE, 801 SAVOY RD. PO BOX 31 YOUNGSVILLE, LA 70592, THE CENTER WILL BE
OPEN UNTIL 5:00P.M. YOU MUST REGISTER BEFORE THE DEADLINE.
I, THE ABOVE NAMED PLAYER, HEREBY CONSENT TO PARTICIPATE IN ALL ACTIVITIES OF THE SPORTS
PROGRAM FOR THE ADULT SOFTBALL LEAGUE AT THE YOUNGSVILLE SPORTS COMPLEX. I
ACKNOWLEDGE THAT THERE IS A SIGNIFICANT RISK OF ACCIDENTAL INJURY WHILE PARTICIPATING
IN AN ADULT OR COED SOFTBALL PROGRAM. I AGREE TO BE FULLY RESPONSIBLE FOR ALL OF MY
MEDICAL EXPENSES INCURRED AS A RESULT OF ANY INJURIES WHICH MAY OCCUR WHILE
PARTICIPATING IN THE PROGRAM.
I HEREBY AUTHORIZE AND GRANT PERMISSION TO THE YOUNGSVILLE SPORTS COMPLEX, ITS
COACHES OR LEAGUE REPRESENTATIVES TO AUTHORIZE AND OBTAIN MEDICAL CARE FROM ANY
LICENSED PHYSICIAN, HOSPITAL OR MEDICAL CLINIC SHOULD I BECOME ILL OR INJURED WHILE
PARTICIPATING IN LEAGUE ACTIVITIES. I HEREBY AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL
MEDICAL EXPENSES IN THE EVENT EMERGENCY TREATMENT IS REQUIRED AS A RESULT OF ANY
INJURIES RECEIVED WHILE PARTICIPATING IN LEAGUE ACTIVITIES.
THE NAME OF MY INSURANCE CARRIER IS:
MY POLICY NUMBER/GROUP NUMBER IS:
_
I HEREBY ASSUME ALL RISK AND HAZARDS INCIDENTAL TO PARTICIPATION IN THE ADULT SOFTBALL
LEAGUE AT THE YOUNGSVILLE SPORTS COMPLEX. I DO HEREBY AGREE TO HOLD HARMLESS,
RELEASE AND INDEMNIFY THE CITY OF YOUNGSVILLE, THE YOUNGSVILLE SPORTS COMPLEX, THE
ADULT SOFTBALL LEAGUE ORGANIZATION, ITS COACHES, SPONSORS, SUPERVISORS, OFFICERS,
DIRECTORS AND AGENTS FROM ANY AND ALL INJURIES, CLAIMS, LOSSES AND MEDICAL EXPENSES
ARISING OUT OF OR OCCURRING AS A RESULT OF MY PARTICIPATION IN THE SPORTS PROGRAM.
SIGNED
DATE:________________________________________
SEASON
TEAM NAME