Youth Sports Registration Form


Youth Sports Registration Form
A copy of the player’s Birth Certificate must be submitted with this form.
Player’s Full Name as appears on Birth Certificate
: ________________________________________________________
Nickname: _______________________
Male___ or Female___
Age: ____
Birth Date: _______________
Parents or Guardians: _____________________________________________________________________________________
Home Phone: ______________ Cell Phone: ______________
Email: _____________________________________________
Address: _______________________________________________________________________________________________
City: ______________________________________________________
State: _____
Zip Code: _________
Physician: __________________________________________________
Physician Phone: _______________________
: _______________________________________________________________
Any Medical Conditions, Allergies, ETC
*Please inform the coach of these conditions prior to the first practice
Sport: __________________________________
Season: __________________________
Fee: ______________
Sport Fees:
$35.00 Youth Football & Cheerleading
Uniform Size:
Youth Extra Small
Youth Small
$55.00 Youth Basketball
Youth Medium
Youth Large
$75.00 Boy’s Lacrosse
Adult Small
Adult Medium
$75.00 Girl’s Lacrosse
Adult Large
Adult X-Large
Other Size: _________________
Recreation Scholarship Fund:
Yes, I would like to contribute _____$1.00, _____$2.00 ______$5.00 or other $___________ to the Recreation scholarship
fund. This fund allows children from the Town of Farmville to attend recreational programs in our Town who financially may
not be able to participate. Please include this with your payment. Thank you for your donation!
Parent/Guardian Participation:
I/We understand that Recreation Department conducts fund raising and volunteering activities in addition to the registration fee
and that each player/parent is strongly encouraged and expected to participate. I/We are willing to participate in the following
activities for the Farmville Recreation Department’s Youth Sports Programs.
Check all that apply:
Fund Raise
Maintain Fields
Gate Attendant
Assist Officials
Consent/Waiver Agreement:
I/We consent to our child participating in the Farmville Recreation Department Programs. In participating in Recreation Programs, sponsored by The Town
of Farmville, I hereby acknowledge that I/We understand that there are risks of accidents resulting in bodily harm arising out of those activities. I/We
understand that Recreation activities are planned with the safety of the participants in mind. In case of emergency, accident or illness, if I/We am not present
I/We hereby give our permission for the coach or representative of the Recreation Department to obtain any required medical attention my child may need.
I/We will notify the coach of any physical limitations (allergies, hearing, sight, etc) or other additional information they need to know about my/our child.
I/We further acknowledge that my child has the physical capacity reasonably necessary to engage in Recreation activity for which I have enrolled. I/We
agree to be the party responsible for all medical expenses which are incurred in my behalf. It is understood and agreed that the Town, it’s Mayor, Town
Council, Boards, employees, volunteers and agents shall be held harmless against all claims, damages, loss or expenses including attorney’s fees arising out
of or resulting from participation in recreation programs. I/We agree any pictures taken may be used for future promotions for the Town of Farmville.
___________** I have read the above waiver and understand the contents**
OFFICE USE Only: Cash__ Check #__________ Amount Paid__________ DATE: _____________INT:_____________


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