PLAINVILLE ATHLETIC LEAGUE
2003 REGISTRATION FORM
NAME:______________________________________________ DOB:_____/_____/_____ SEX: M F
LAST NAME FIRST NAME
NAME:______________________________________________ DOB:_____/_____/_____ SEX: M F
LAST NAME FIRST NAME
NAME:______________________________________________ DOB:_____/_____/_____ SEX: M F
LAST NAME FIRST NAME
NAME:______________________________________________ DOB:_____/_____/_____ SEX: M F
LAST NAME FIRST NAME
ADDRESS: ___________________________________________ PHONE: __________________________
CITY: __________________________________ STATE: ____________ ZIP: ______________________
Email Address: ______________________________ Would you like to receive league news via email ? _____
IN CASE OF EMERGENCY PLEASE NOTIFY: ___________________________________________________
PHONE: __________________________________ RELATIONSHIP: ______________________________
Do you have health insurance coverage? __________
Name of Provider (Insurance company): ________________________________________________________
Any special health issues that the league needs to know about? ____________________________________
__________________________________________________________________________________________________________________________________
PLEASE READ CAREFULLY !
I/We the parents of the above named candidate for a position on a Plainville Athletic League team, hereby
give my/our approval for his/her participation in any and all Athletic League activities during the current
season. I/We assume all risks and hazards incidental to such participation, including transportation to and
from activities; and I/We hereby waive, release, absolve, indemnify and agree to hold harmless the Plainville
Athletic League, the organizers, sponsors, supervisors, participants, and persons transporting my/our child/
children to or from activities, for any claim arising out of injury to my/our child/children. I/We assume all
responsibility in the event of their injury. I/We agree to return upon request the uniform and any other equip-
ment issued to our child/children in as good a condition as when received, excepting normal wear and tear.
PARENT / LEGAL GUARDIAN SIGNATURE: __________________________________ DATE: _____________
(DO NOT WRITE BELOW THIS LINE - FOR LEAGUE USE ONLY) ______________________________________________________________________
FEE: _____________________ DATE PAID: _______________________ CASH: _________________
AMOUNT PAID: _________________ __________________ CHECK: _______ CHECK # ___________
VOLUNTARY CONTRIBUTION TO THE IRRIGATION PROJECT: ________________
BALANCE DUE: _____________________ ______________________ S __________
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