For the Player:        

Last Name:		First:		Mi:		Birth Date:

     

Address:		City:		Zip Code:

       

School:		Grade:		Seasons in this sport:		Seasons in other sports:

     

Do you have medical insurance:	Yes No	Carrier:		Number:

   

Doctors Name:		Phone:

Please list any medical condition(s), disabilities, present injuries, heart or respiratory illness or other conditions, that may effect this child's ability to play:

 

List Medical Conditions

Father/Guardian

Father Last Name:		Father First Name:		Father Home Phone:		Father Work Phone:

Mother/Guardian

Mother Last Name:		Mother First Name:		Mother Home Phone:		Mother Work Phone:

Emergency Authorization

If there is an emergency during participation in this program and I or another parent or guardian is not present, I authorize treatment and/or care at any hospital and I hereby authorize the volunteers and staff of this program as my agents. If I cannot be reached please contact the following person who is hereby authorized on my behalf:

   

Emergency Contact:		Contact Phone:

DISCLAIMER,ASSUMPTION OF RISK AND WAIVER:

To accept registration and permit participation in Knox County programs by the named participant, I the parent or guardian of said participant, hereby give my consent and agree to release, indemnify, and hold harmless Knox County, its officials, coaches, representatives and volunteers from any claim arising out of injury or death. For myself and on behalf of my heirs, assigns and next of kin, I acknowledge that participation in this program my include travel, participation on adverse field conditions, and risk of physical injury or death. For myself and on behalf of my heirs, assigns and next of kin, I willingly and voluntarily accept and assume all such risks of participation. I hereby release, discharge and agree to hold harmless Knox County, its employees, volunteers, officials, sponsors and other representatives from any and all claims, demands costs, expenses and compensation arising out of or in any way related to any injury or other damage that may result to the participant while participating in this Knox County sponsored activity.

INSURANCE ACKNOWLEDGEMENT

I acknowledge that Knox County provides limited, secondary medical insurance to serve as a supplement to my primary medical insurance and will serve as primary coverage only in the event I have no medical insurance (please see Knox County for limits of insurance coverage and deductibles).

I am interested in volunteering for:

Volunteer:	Coach Asst. Coach Team Parent Concessions Other

I,parents, or legal guardian agree that by signing or by checking yes have read and understood the above information.

I agree to terms above:	Yes No

 

Date:

Your coach will provide you with his/her name and number. Thank you for registrating. Make your check payable to ABSH BALLPARK in the amount of $65.00, or $70.00 if after deadline of March 10th. You may mail your check to Tonya Waddell 5729 Kentwood Drive Knoxville, Tn 37912. Please remember, after completing the form to click on the submit button.