2016 SGS Fall Youth Sports Registration

Today’s Date: / Tackle Football A
$125.00 / Ages 6-13 / Cheerleading
$125.00 / Join our Facebook Page:
South Greenville sports SGS Wildcats

Player INFORMATION

First name: / Middle: / Last: / Nickname:
Street Address: / City: / State: / ZIP:
Phone: / School: / Date of Birth: / Weight (Football Only):
Pant / Skirt Size: Youth Adult
XS SM M L XL / Shirt Size: Youth Adult
XS SM M L XL / Jersey # Requested (List 3):

Parent/Guardian INFORMATION

Parent 1 / Parent 2
Name: / Name:
Phone: / Alt. Phone: / Phone: / Alt. Phone:
E-mail: / E-mail:

Medical & Emergency INFORMATION

Emergency Contact: / Emergency Phone: / Relation to Player:
Insurance Carrier: / Policy #: / Pref. Doctor: / Phone:
Please list any allergies/medical problems, including those requiring maintenance medications. (i.e. Diabetic, Asthma, Seizure Disorder)
Medical Diagnosis / Medication / Dosage / Frequency of Dosage

Medical Treatment (required):

(initial above - I hereby give permission for South Greenville Sports to use its judgment in obtaining medical service for my child on an emergency basis. I give permission to the physician selected bySouth Greenville Sports to render medical treatment deemed necessary and appropriate. In the event I cannot be contacted, I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical and hospital care treatment and procedures (including but notlimited to, administration of necessary anesthetics, tests, x-ray examinations, transfusions, injections, drugs) to be performed for my child by a licensed physician or hospital selected by an agent of South Greenville Sports when deemed immediately necessary or advisable by the physician to safeguard my child's health.I agree to assume responsibility for payment of any resulting medical, hospital or related costs and expenses.

Release From Liability (required):

(initial above) I understand that accidents may occurfrom my child's participation in sports activities carried out by South Greenville Sports. Iagree to assumethose risks.By signing below, I release South Greenville Sports, its agents, volunteers, coaches, board of directors, andindependent contractors, league officials and sponsoring agencies from any and all liability based on any damage, loss or injury whether it is the result of ordinary negligence orotherwise, causedto my child or to me from participationin the South Greenville Sports.

Photo Release (optional):

South Greenville Sports may at times post pictures from events, practices and games on the South Greenville Sports website. NOTE: We do not list the child’s name as a caption on any pictures.

Parent Name (print) / Parent Name (Sign) / Date:

Please include copy of birth certificate & payment with your registration form when you register at your chosen registration date.

League Use Only

Birth Certificate Waiver Required Physical Form (Football) / Amount Paid: $
League Age: / Division: / Team: / Jersey # Assigned: / Cash Check M/O