Amelia County Parks & Recreation
Deadline: September 1st, 2017, $20.00 late fee begins
Dixie Youth Girl’s Softball League
FALL 2017
AGE GROUPS:
Sweetees (4-6 yo)
Darlings (7-8yo)
Angels (9-10yo)
Ponytails (11-12yo)
Belles (13-15yo)
Debs (16-18yo)
*Birth Certificates and Physicals and Fees are REQUIRED before practice begins*
(Print Whole Name as printed on Birth Certificate)
Player’s Name:_________________________________________
Home Phone: ______________
LAST NAME, FIRST NAME & MIDDLE NAME
Cell Number: _____________
Home Address: _______________________________________ City, State & Zip: ________________
Email Address: ________________________________________________________________________
(
st
Birth Date: _________________ Age: ______ as of January 1 current year)
Has your child ever participated in this program before? Yes or No (Circle One)
How many years? _________
What position? __________________________________
Uniform Sizes:
Jersey: ___________ Shorts: ____________
I will volunteer to: (Please put and X in the box)
Coach ____
Assist. Coach _____ Litter Control _________ Newspaper Ad ____
Field Maintenance _____
Umpire _____
Fundraiser ___________
Sponsorship _____
Donation _________
Scorekeeper _____________
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Parks and Recreation must have a copy of your child’s birth certificate and physical on file BEFORE the child will be allowed to
participate.
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A registration fee of $60.00 and a Concession Fee of $25.00 for each player must be paid at the time of sign-up, no uniform will be
issued until all fees are paid in full. There will be an added $20.00 fee for late registrations at the date above. Any cancellation
result in a $20.00 (non refundable) processing fee. Any exceptions must be approved by Glen Wilkerson.
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No REFUNDS will be made once uniforms and equipment have been ordered.
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All parents are required to work 4 hour per child concession hours for this 2017 season. You will receive your reimbursement once
your concession has been completed for each child (allow 7-10 business days for processing) All schedules will be scheduled
through your coach or you may email dates to work to [email protected].
($60.00) fees are required before uniforms will be given out. Schedules will be scheduled through your coach.
I, parent/guardian of the child whose name is listed above, hereby gives approval for her participation in this youth program. I absolve Amelia County Parks & Recreation, its officials,
coaches, and volunteers of any liability for injuries to the child listed above occurring during participation, necessary or accidental activities sanctioned by Amelia County Parks &
Recreation. Please note with any injury due to participation; our insurance will serve as a secondary insurance, and will be limited in nature. I will file my claims with my insurance
before submitting any to Amelia County Parks & Recreation department. I have provided a physical and/or doctor’s approval for my child to participate in this organized sport and to
approve of them to participate in a full contact sport which will involve running, jumping, hitting and other strenuous exercise activities for this current season. All sports and
activities are at your own risk. I understand any photos takes at games, practices and tournaments during the season are the property of Amelia County Parks & Recreation and I give
permission for their use as they see fit to use. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND
THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Parent/Guardian: ______________________________________________________________________
(Print)
Parent/Guardian: _______________________________________________________ Date: __/__/__
(Signature)
Please do not write below this line. Staff Use ONLY
Assigned Team Name: ___________________________________ Coach _______________________________
Phone: _________________
Birth Certificate ___________________
Physical ___________________ Fee Received ______________ Cash __________
Check# ______________
(Cert. Id#)
(Expiration Date)
(Date Recv’d)
Amelia County Parks & Recreation
Code of Ethics Pledge for Parents
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I will encourage good sportsmanship by demonstrating positive support for all the players, coaches
and officials at every game, practice or other youth sports events.
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I will place the emotional and physical well-being of my child ahead of any personal desire to win.
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I will insist that my child play in a safe and healthy environment.
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I will support the coaches and officials working with my child to provide a positive, enjoyable
experience.
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I will remember that THE GAME IS FOR THE CHILDREN and NOT THE ADULTS.
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I will do my best to make youth sports fun for my child.
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I will ask my child to treat other players, coaches, fans and officials with respect regardless of race,
sex, creed or ability.
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I will promise to help my child enjoy the youth sports experience by assisting with coaching, being a
respectful fan, and providing transportation or whatever I am capable of doing.
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I hereby pledge to provide positive support, care and encouragement for my child’s participation in
Youth Sports by following the NYSCA Code of Ethics.
(Adopted from the National Youth Sports Coaches Association)
I have read, understood and agree to abide by the Amelia County Parks & Recreation Code of Ethics.
Signature: ___________________________________________________________
Date ___/___/___