DICKSON DOLPHINS

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2014 DICKSON DOLPHINS REGISTRATION FORM

PLAYER/CHEERLEADER INFORMATION

* ACTIVITY:

* First Name:

* Last Name:

Name child goes by:

* Street Address:

* City:

* Is this address within the City of Dickson?:

* Gender:

* Birthdate:

* AGE (On August 1st):

Insurance Carrier:

Policy #:

* ALLERGIES OR KNOWN MEDICAL CONDITIONS:

ANY SPECIAL NEEDS OR CONCERNS FOR THE CHILDS' COACH:

PARENT/GUARDIAN #1 (primary caregiver)

* Firstname:

* Lastname:

* Street Address:

* City:

* Home Phone:

* Work Phone:

* Cell Phone:

EMail:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Street Address (if different):

Home Phone:

Work Phone:

Cell Phone:

Email:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact (other than parent):

* Phone:

* Relationship to Player:

WAIVER INFORMATION

I, AS PARENT/GUARDIAN OF THE ABOVE LISTED CHILD, DO HEREBY GRANT, IN MY ABSENSE, THE AUTHORITY TO THE COACHING STAFF OF THE DOLPHIN ORGANIZATION TO RENDER JUDGEMENT CONCERNING MEDICAL ASSISTANCE OR SURGICAL DIAGNOSIS AND TREAMENT WHICH MAY BE DEEMED NECESSARY.

I HEREBY GIVE CONSENT AND WISH TO HAVE MY CHILD ENROLLED AND ACTIVELY PARTICIPATE IN THE DOLPHIN ORGANIZATION.

I / We agree with the above. *

THE DICKSON DOLPHINS IS A VOLUNTEER ORGANIZATION. THERE ARE A NUMBER OF TASK THAT MUST BE DONE BEFORE, DURING, AND AFTER GAMES AS WELL AS AT PRACTICES. IT TAKES A CO-OPERATIVE EFFORT OF VOLUNTEERS, BOTH PARENTS AND COACHES, TO ACHIEVE THIS AND TO KEEP OUR COST DOWN.
EVERY CHILD SHALL HAVE A PARENT OR GUARDIAN WORK IN THE CONCESSION STAND, ASSIST WITH FIELD PREPARATION, ASSIST WITH FIELD CLEAN UP, RUN THE CLOCK, RUN THE SIDE LINE CHAINS, AND/OR OTHER DETAILS THAT MAY ARISE ON AN AS NEEDED BASIS.

I / We agree with the above. *

* Print Name::

Signature. (Checking this box becomes my electronic signature.) *

Signature:

Date:

* indicates required fields

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2014 DICKSON DOLPHINS REGISTRATION FORM