Tierra Canyon Girls Softball - Registration Form

10601 Tierrasanta Blvd. #273, San Diego, CA 92124

(858) 268-4636 ext. 500

www.tierrasantasoftball.org

Registration Information:

Name: ________________________________________________________________________

Address: _________________________________________________ City: __________________

e-mail: __________________________________________________ ZIP: _________________

Telephone: ______________________________ School: ___________________________________

Birthdate: _______________________ Age as of 1/1/06: _____________

Parents’ Name(s): _________________________________________________________________

Emergency Contacts:

Name: _____________________________________ Phone: ____________________________

Name: _____________________________________ Phone: ____________________________

Previous Experience:

Number of years played: _____________ Where: ________________________________________

Medical Information:

Insurance carrier and group/ID number: _______________________________________________

Allergies or medical conditions: _______________________________________________

Sister(s) playing at same level: _____________________________________________________

Emergency Authorization:

I, the undersigned parent or legal guardian of the participant, a minor, hereby authorize the managers, coaches or parents of team members acting in the capacity of activity supervisors or vehicle drivers, as my Agents, to consent to medical, surgical or dental examination and/or treatment in the event of any injury caused by a direct or an indirect result of the participant’s participation in Tierra Canyon Girls Softball / ASA activities.

Informed Consent:

I, the parent or legal guardian of the above named individual, acknowledge that participation in athletic events necessarily involves risk of physical injury. In consideration for accepting the registration of the above named individual and permitting voluntary participation of said individual in its programs, I hereby release, discharge and hold harmless Tierra Canyon Girls’ Softball, its volunteers and other representatives from any claims arising out of or relating to any physical injury that may result to said individual while participating in Tierra Canyon Girls Softball sponsored events, including any physical injury caused by the negligence of any official, manager or coach while performing his/her duties during any practices or games. I also agree to return any equipment loaned to my daughter, or me in as good condition as when received (excepting wear).

Parent/Guardian’s signature:_____________________________________ Date: _______________

We heard about Tierra Canyon through: [ ] Tierra Times [ ] Flyer from School [ ] Friend/Family

[ ] Mailing [ ] Community Posting [ ] Returning [ ] Other _______________

2006 Season - $100 fee, one $10 Discount per family for Military or a sibling, $15 late fee after 1/7/06. Make checks payable to: Tierra Canyon Girls Softball

FOR LEAGUE USE ONLY:

Division: ___________________________ Manager/Team: ________________________________

Fees received by: _____________________ Check # __________________Amount: _____________

Date fees received: ___________________ Birth date verified by: ____________________________