The City of Grove City Parks & Recreation Department
614-277-3050 • 3226 Kingston Ave., Grove City, OH 43123
www.GroveCityOhio.gov • facebook.com/GroveCityOhio • twitter.com/GroveCityOhio
YOUTH S PORTS R EG I S T R AT I ON
PLAYER INFORMATION
CHILD’S LAST NAME FIRST NAME MI GENDER
Male Female
HOME ADDRESS CITY STATE ZIP
GRADE BIRTH DATE MM/DD/YYYY
SCHOOL ATTENDING
HEIGHT YEARS EXPERIENCE
Rec. ____ Travel ____ School ____
CHILD CURRENTLY PLAYS THIS SPORT ON THE SCHOOL TEAM
Yes No
SPORT UNIFORM SHIRT SIZE Clothing sizes may vary by sport. If unsure, choose a larger size.)
Basketball Volleyball YS YM YL AS AM AL AXL AXXL
PARENT/GUARDIAN INFORMATION
PARENT/GUARDIAN NAME
Residential parent/guardian
Interested in coaching
DAYTIME PHONE CELL/OTHER PHONE EMAIL
PARENT/GUARDIAN NAME
Residential parent/guardian
Interested in coaching
DAYTIME PHONE CELL/OTHER PHONE EMAIL
EMERGENCY CONTACT (NOT LISTED ABOVE) RELATIONSHIP
DAYTIME PHONE CELL/OTHER PHONE EMAIL
MEDICAL INFORMATION/SPECIAL CIRCUMSTANCES
Does child have any medical problems/allergies? Yes No Describe:
Describe any special circumstances:
In consideration of acceptance as a member of the Grove City Parks and Recreation program, I do hereby, for myself, executors and administrators, waive,
release and forever discharge of all claims for any and all damages, which may be sustained and suffered by the above child in connection with his/her said
association with and/or entry into games, exhibitions and/or practice sessions which may herein after occur to me against the Grove City Parks and Recreation
Department, the South-Western City School District, their sponsors, administrators all their respective ofcers, agents, representatives, successors and/or assigns.
In further consideration for such recreation and training being afforded my child, I do hereby release and discharge the Grove City Parks and Recreation Department, the South-
Western City School District, their ofcers, coaches, assistants and their appointees any and all of them, from any claims, liabilities, damages or demands for any injuries to
person or property, sustained by the above named child and resulting from their participation, practice or play for the aforementioned organization. Should the above named child
become ill or injured and a parent or guardian cannot be contacted, permission is hereby granted to call a licensed physician for treatment or to transport said child to a hospital
emergency room for treatment. Further the undersigned will indemnify and hold harmless the City of Grove City, its ofcers, employees, sponsors, administrators, agents and all
other persons, whoever, from any and every claim or demand of every kind of character, which may be asserted by reasons of any injuries or the effects or consequences thereof.
I agree to abide by the written rules, policies and spirit of Grove City Parks and Recreation Department, and that all programs are for the sole benet of the
children participating. I acknowledge the authority of the Administrator of Sports. I further agree to abide by any decisions made by the administrator not
specically covered by the Grove City Parks and Recreation Department, written bylaws or policies. I further understand that photographs or video are occasionally
taken of programs and class participants associated with The City of Grove City. These images may be used in a variety of City of Grove City materials.
PARENT/GUARDIAN SIGNATURE DATE
©2012 CITY OF GROVE CITY
FOR OFFICE USE ONLY
LEAGUE
Parent is coach
Associated with sponsor
RECEIPT #
