Church Hill, TN - Sport Registration

Participant Name: Participant Name: First Last
Participant Address: Participant Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth:
Gender:

Gender: Male Female
Current Grade
Parent/Guardian Name Parent/Guardian Name First Last
Parent/Guardian Address: Parent/Guardian Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone: Phone: - ### - ### ####
Parent/Guardian email address:
Other Emergency Contact: Other Emergency Contact: First Last
In the event we are unable to contact parent/guardian.
Relationship to Participant:
Emergency Contact Number: Emergency Contact Number: - ### - ### ####
Family Doctor: Family Doctor: First Last
Phone Number: Phone Number: - ### - ### ####
Special Needs/Medications/Allergies:
How would you Like to receive message?

How would you Like to receive message? Text Email Both
Would you be willing to be a head coach?

Would you be willing to be a head coach? Yes No
Would you be willing to be an assistant coach?

Would you be willing to be an assistant coach? Yes No
Sport:
Participant T-Shirt Size:

Participant T-Shirt Size: Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult XL Adult 2X Adult 3X
Registration Fee

Registration Fee Hawkins County Resident Hawkins County Non Resident

Hawkins County Resident Fee - $30.00 and Out of County fee - $35.00 per participant
Sudden Cardiac Arrest Symptoms and Warning Signs

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Parent/Guardian/Child Acknowledgement

Parent/Guardian/Child Acknowledgement I have read and reviewed the Sudden Cardiac Arrest Symptoms and Warning Signs with the participant.

Read form above.
Children's Rights - Parent's Pledge

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Parent/Guardian/Child Acknowledgement

Parent/Guardian/Child Acknowledgement I have read and reviewed the Children's Rights - Parent's Pledge Document with Participant.

Read form above.
Concussion Statement

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Parent/Guardian/Child Acknowledgement

Parent/Guardian/Child Acknowledgement I have read and reviewed the Concussion Statement with the participant.

Read form above.
Parental/Guardian Emergency Authorization:

Parental/Guardian Emergency Authorization: I hereby authorize the coaches, assistant coaches, or parent of team members acting in the capacity of activity supervisor as agents to consent to medical, surgical, or dental examination, on an emergency basis. In case of emergency, I hereby authorize treatment and/or care of registered player at any hospital.
Parental/Guardian Authorization/Waiver:

Parental/Guardian Authorization/Waiver: To induce the Church Hill Recreation to accept registration and permit participation in the youth league by individual named above, I, the parent/guardian of said individual, herby give my consent and agree to release indemnify, and hold harmless Church Hill Recreation, its officials, coaches, and representatives, from and claim arising out of injuries or conditions caused by our/my refusal to seek or obtain available medical treatment for the child.
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Church Hill, TN - Sport Registration

Sudden Cardiac Arrest Symptoms and Warning Signs

Children's Rights - Parent's Pledge

Concussion Statement