Registration Form

Submitted by bridge on Tue, 01/19/2010 - 22:21

BRIDGE VOLLEYBALL CLUB
CONSENT / REGISTRATION
This form must be completed by child’s parent or legal guardian.

Parent’s consent to allow participation and authorization to treat the minor named below, my child, is hereby given my content to physically participate in activities of volleyball protected by the USA Volleyball Insurance Program and I assume all risk and hazards. I will prove my child with court shoes and other gear as needed. I realize that the registration fee is nonrefundable. While participating in volleyball, I will make certain that my child does not wear jewelry of any type. I will promptly pick my child up from practice and tournament that are scheduled.

In an emergency, every effort will be made to contact me (us). I, the undersigned parent/guardian of the child, a minor, do hereby authorize/consent to any x-ray, anesthetic, medical or surgical diagnosis rendered under general or special supervision of any member of the medical/emergency staff licensed under the provisions of the Medical Practice Act, or a dentist licensed under the provisions of the Dental Practice Act and on the staff at any acute general hospital licensed by the Sale Department of Public Health. This authorization is given pursuant to the provision to the civil code in California. Constant expires 12/31/2010.

Programs of Interest:

Player's First Name: *

Player's Last Name: *

Player's Date of Birth: *

Player's School Name: *

Player's Grade: *

Player's Address: *

Player's City: *

Player's State: *

Player's Email: *

Player's Phone: *

Player's Physician's Name:

Player's Physician's Phone:

Any current physical conditions preventing the child’s immediate and full physical participation : *

Player's Medical Overview: *

List all health information know about your child including
- Medications being taken
- Physical Restrictions including hearing/vision limitations
- Physical impairments; prosthesis; allergies; asthma
If no medications are being taken and there are no physical restrictions, write NONE for this field.

Player's Shirt Size: *

Child lives with?: *

Parent or Guardian's (1) Name: *

Parent or Guardian's (1) Complete Address:

If you live at the same address as the player, you can leave this blank.

Parent or Guardian's (1) Phone Number: *

Parent or Guardian's (1) Email Address: *

Preferred Method of Payment: *

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