BedfordCountyParks and Recreation Department

Moneta Recreation Association Registration Form

Circle a sport/activity: Football Cheerleading Soccer U6 U8 U10 U12 U15 Circle one: Returning NEW player

PLAYER’S

NAME______Birth Date:______Age:______Gender: _____

First Middle Last

School currently attending: ______Last year school attended: ______

Parent’s/Guardian’s Name: ______County of Residence:______

Parent’s/Guardian’s Address:______City______Zip ______

Home Phone: ______Cell Phone: ______e-mail Address: ______

Parent’s/Guardian’s Name: ______County of Residence:______

Parent’s/Guardian’s Address:______City______Zip ______

Home Phone: ______Cell Phone: ______e-mail Address: ______

PARENT/GUARDIAN CONSENT:

  1. Each participant, parent/guardian registering their child, as well as all individuals present at any BedfordCountyParks and Recreation sponsored activity must agree to and abide by the Parks and Recreation Code of Conduct.
  2. A Parent/guardian, who legally resides in the County of Bedford, may register his or her child to participate in a BedfordCountyParks and Recreation Department athletic league. A youth player who registers to play in a Parks and Recreation League may play with or be registered to any other non-department sponsored team or league. However, a player's first obligation pertaining to practices and games must be to his or her recreation team. Any player who misses a recreation team practice or game may be subject to disciplinary measures approved by the Parks and Recreation Department and initiated by that team's head coach.
  3. It is the responsibility of the parent/guardian to provide transportation to and from practices and games. Upon arrival, parents should make sure a coach is present. Players should be picked up directly after activities are completed.
  4. It is the responsibility of the parent/guardian to return equipment furnished by the Parks and Recreation Department to the coaches no later than one week following the team's last game. A player who fails to return all equipment will not be permitted to participate in any Bedford County Parks and Recreation athletic program until all equipment has been returned.
  5. I/we am aware of the activities and I understand that the Parks and Recreation Department employees and all Recreation Association agents, coaches and volunteers are not responsible for determining whether my child is physically and/or mentally fit for this program.
  6. I/we understand that any incorrect or false information provided on this form will result in the player being declared ineligible immediately and for the remainder of the season.
  7. By acknowledging this consent, parents/guardian(s) are notified that the Parks and Recreation Department employees and all Recreation Association agents, coaches and volunteers are not responsible in case of an accident, injury, or death while playing or participating in this youth athletic program.
  8. I/we hereby release BedfordCountyParks and Recreation and all Recreation Association agents, coaches and volunteers from any and all claims and/or liability as a result of personal injury and/or property damage arising from the above child's participation in this athletic program.
  9. I/we further authorize commission officials to take the proper steps to provide medical attention should my child be injured while playing or being transported to or from any Recreation Commission sponsored activity. I hold said officials and the Recreation Commission harmless therefore.

I/we hereby have read and agree to the above and give my consent for the above child's participation, furthermore, I/we verify that all information stated on the registration is true. I/we the undersigned have read this release and understand all its terms. I/we execute it voluntarily and with full knowledge of its significance.

REGISTRATION FEES IF PAID BEFORE OR BY June 30th - $45 per child. If paid AFTER June 30th - $55 per child.

We encourage all to sign up ASAP, to help organize the teams, coaches, schedules and to avoid late fees. You may sign up online at or by mail, send this signed form with payment to:

Moneta Area Recreation Association

PO Box 803

Moneta, VA 24121

If you have questions please contact Tammy Goode at (540)330-9360 or by email at

I/we hereby have read and agree to the parents’ consent and parents’ code of ethics. Furthermore, I/we verify that all information stated on the registration is true. I/we the undersigned have read this release and understand all of its terms. I/we execute it voluntarily and with full knowledge of its significance.

______

Signature of Parent(s)/Guardian(s) Date

**FALL SIGN UPS**

Fall sports include:

*Football (5 – 12 years of age) – must be 5 by August 1, 2016

*Cheerleading (4 – 12 years of age) – must be 4 by August 1, 2016

*Soccer (4 – 18 years of age) – must be 4 by August 1, 2016

Registration fee is $45if paid during the month of June.

After June 30th – Registration fee is $55.

Registration fee is due at time of registration.

Completed registration forms can be mailed to:

Moneta Area Recreation Association

PO Box 803

Moneta, VA 24121

Or

Online Registrations are open 24 hours a day at

Any questions please contact Tammy Goode at (540)330-9360 or by email at

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