Cost of Program Is $30.00 Resident Or $45.00 Non-Resident ATHLETICS REVISED 2016

Cost of Program is $30.00 resident or $45.00 non-resident ATHLETICS REVISED 2016

PERSON COUNTY RECREATION, ARTS AND PARKS DEPARTMENT YOUTH VOLLEYBALL PLAYER REGISTRATION FORM

______Male_____ Female______Participants Name (as it appears on birth certificate) Date of Birth

______Address City/State Zip

______Mother’s Name Father’s Name E-mail Address

______Recreation Insurance __Y___N Mother Phone Number Father Phone Number

Would you like to coach ____Yes ____No What age group Shirt Size

2014 Coach Name

Special Request:

Please be sure to make a note if you prefer your child not to play with a previous coach or child even if they’re not playing or coaching. Request can be suggested but NO GUARANTEE. No request will be noted if your child/children do not attend skills day.

I, the undersigned, hereby agree to carefully observe and faithfully abide by the rules and regulations of the Person County Recreation, Arts and Parks Department and the league to which my child’s team is a member. I do hereby waive, release, absolve and hold free of liability, my child’s team, their organizers and supervisors and Person County, its Recreation, Arts and Parks Department, or any of their personnel, from any claim or loss arising out of or related to any injury received while playing, practicing, or traveling during the current season. Furthermore, I agree to return any paraphernalia or property held by me and belonging to my child’s team or the Person County Recreation, Arts and Parks Department upon termination of my contract with my child’s team.

______PRINT PARENT’S/GUARDIAN’S NAME

______PARENT/GUARDIAN’S SIGNATURE DATE

I give my permission and grant to the Person County Recreation, Arts and Parks Department the right to make pictures and sound recordings of my child and the right to use such pictures and sound recordings, including the right to identify my child’s name, likeness, voice and words, in television, film, newspaper, magazine, internet, and other media of any form, for the purposes of advertising and communicating the purpose and activities of the Person County Recreation, Arts and Parks Department and for the purpose of applying for funds to support those purposes and activities.

______PARENT’S/GUARDIAN’S SIGNATURE

MUST HAVE BIRTH CERTIFICATE ON FILE BEFORE SKILLS DAY TO BE ELIGIBLE TO PLAY.