Norrisville Baseball

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2023 Registration Form

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Email:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

I certify that the individual named above is in good physical condition and is capable of participating in the named program. If medical attention beyond first aid treatment is required, I understand that every attempt will be made to contact me at the emergency number provided. If contact with me is not possible, I give permission for medical attention to be administered. Furthermore, I hereby release, exonerate and discharge the organizers, officers, volunteers, coaches, officials, representatives, employees, and agents from any and all actions and for any injuries or damages incurred while participating in, or traveling to and from, this program.

In accordance to Maryland law, I hereby acknowledge that I have received the information regarding concussions published by the United Sates Department of Health and Human Services Centers for Disease Control and Prevention (CDC). For additional information, I understand that I may call 1-800-232-4636 or go to http://www.cdc.gov/concussion/headsup/youth.htmlaiver information here ***

I/we agree with the above *

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2023 Registration Form