Havelock Girls Softball League 2009 Regular Registration – Consent for Treatment-Waiver of Liability Form For Official Use Only: League Official Initial: ________ Registration Date:______________________ Clothing Total: $____________ Age Bracket:_________ Dual Roster Age Bracket____________ Cost: $45 single\ $30 (sibling)\ $75 (dual) Total Amount Paid: Cash $_______ Check $________ #________ AMOUNT AMOUNT Babe Ruth Card: On File – Verified \ New Card-(Birth Certificate Verified) attached with Form. *** NOTE: Returned Check Fee of $35 will be paid by Registrant *** Birthdate _______________________ Player’s Last NameFirstMI Age as of 01/01/09________________ ________________________________________________________________________________________________________ Street Address / Apartment #CityStateZip CodeHome Phone ________________________________________________________________________________________________________ Address of Parent(s) _____________________________ Emergency Contact Name Home or Cell PhoneWork or Cell Phone ________________________________________________________________________________________________________ Special Medical Conditions AllergiesMedications LEAGUE WAIVER OF LIABILITY _____ We, the parents or guardians of the above named individual, acknowledge that participation in athletic events necessarily involves risk of physical injury. _____ We, the parents or guardians of the above named individual, do hereby assume responsibility for any injury incurred that may result from participation in the Havelock Girls Softball League (HGSL). _____ We, the parents or guardians of the above named individual, hereby remise, release, and forever discharge the HGSL and all others listed hereafter: property owners permitting the use of their land or vehicles for softball activities, organizers, commissioners, sponsors, officers, board members, coaches, participants, referees, the staff and administration of Havelock Parks and Recreation from any and all actions, claims, and demands, loss or injury sustained in consequence of participation in the HGSL. LEAGUE CONSENT FOR TREATMENT _____ In case of serious accident or illness, we, the parents or guardians of the above named individual, do hereby authorize a representative (a team manager, coach, or designated team adult) of HGSL to use his/her judgment on obtaining immediate medical care. After a reasonable attempt has been made to obtain parental/guardian consent or if sound medical practice decrees there is not time to make this attempt, we consent to any necessary x-ray, examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the registrant under the general or special supervision and advice of a physician/surgeon/dentist duly licensed to practice medicine. LEAGUE GENERAL CONSENT _____ We, the parents or guardians of the above named individual, agree to abide by and adhere to the rules, regulations, and decisions of the HGSL and agree to any disciplinary actions taken by the HGSL board members, officers, and referees for infractions. We, _________________________________________, the parent(s) / legal guardian(s), of the registrant, Parent/Legal Guardian Signature __________________________________, a minor child wishing to participate in the Havelock Girls Softball League, Printed Name of Player attest that we have read, fully understand, and agree to this medical consent and waiver of liability form. We grant permission for the above named registrant to participate in HGSL 2009 Season. Accident Insurance Co. _____________________________ Accident Insurance Policy No._______________________