ANNUNCIATION CATHOLIC YOUTH ORGANIZATION
2015 SPRING PLAYER REGISTRATION FORM
PLAYER INFORMATION:
PLAYER NAME_____________________________________________________________________________________________
ADDRESS __________________________________________________________________________________________________
CITY _____________________________________________________________ STATE _________ ZIP CODE_______________
HOME TELEPHONE: (________)________________________________ CELL PHONE (_________)______________________
EMAIL ADDRESS:___________________________________________________________________________________________
BIRTHDATE (MM/DD/YY) _____/_____/_____
GRADE ATTENDING IN SPRING 2015 ________
SPRING SPORT(S): Please select all sports player is registering for Spring 2015 (cost is per player)
VARSITY BASEBALL (grades 7-8) $110 __________
JV BASEBALL (grades 5 -6)
$110 ___________
TRACK (grades 4-8) $75_____________
VARSITY GIRLS SOFTBALL (grades 7 -8) $85 ______
JV GIRLS SOFTBALL (grades 5-6) $85 ______________
PEE WEE TRACK (grades 1st-3rd) $40_____________
* THERE IS A FAMILY LIMIT OF $225 FOR THE SPRING 2015 SEASON*
PARENTS INFORMATION:
Parents Name ____________________________________________ Parent CELL PHONE (_______)________________
Parent WORK PHONE (______ )______________________________________
Parent ___________________________________________ Parent CELL PHONE (_______ )________________
Parent WORK PHONE (______ )_______________________________________
INSURANCE/EMERGENCY CONTACT INFORMATION:
Is the above named child covered by health insurance: Yes
No
POLICY HOLDER’S (PH) NAME _______________________________________________ PH’s DATE OF BIRTH (MM/DD/YY)___________
ADDRESS______________________________________________________________________________________________________________
CITY/STATE/ZIP________________________________________________________________________________________________________
PH’s EMPLOYER________________________________________________________________________________________________________
EMPLOYER’S ADDRESS_________________________________________________________________________________________________
INSURANCE CARRIER__________________________________________________________________________________________________
POLICY #_____________________________________________________________
GROUP #______________________________________
LIST ANY MEDICAL CONDITION OR PROHIBITION OF REGISTRANT
_______________________________________________________________________________________________________________________
MEDICAL EMERGENCY CONTACT ________________________TELEPHONE (_____)___________________________________________
DOCTOR NAME _______________________________________________TELEPHONE(_____)_______________________________________
CONSENT FOR MEDICAL TREATMENT (MINOR) – As the parent or legal guardian of the above named registrant, I hereby give consent for emergency
medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry.
Signature of Parent/Guardian _______________________________________________________________________________ Date___________
GENERAL INFORMATION:
CURRENT SCHOOL ____________________________________________________________________________________________________
GRADE __________
I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the ABVM CYO, its affiliated organizations, and sponsors.
Recognizing the possibility of physical injury associated with and in consideration for the ABVM CYO accepting the registrant for its games and activities, I hereby
release, discharge , and /or otherwise indemnify the ABVM CYO, its affiliated organizations and sponsors, their members and associated volunteers, including the
owners of fields and facilities utilized for the programs, against any claims by or on behalf of the registrant as a result of the registrant’s participation in the Programs,
and/or being transported to or from the same, which transportation I hereby authorize. In addition, I grant the ABVM CYO, and its affiliated organizations, and
sponsors, the right to use the registrant’s name, picture and/or likeness in printed, broadcast and other material concerning the games and activities, provided such use is
related to the registrant’s status as a participant in the games and activities.
Name of Parent/Legal Guardian (Please Print) __________________________________________________
Signature X________________________________________________________________ Date:___________
Please make check payable to: Annunciation Athletics. ( Payment must be made at the time of Registration.)
Mail form and payment to:
Kathy Martin, Treasurer kmartin7@comcast.net. 212 Pineridge Road, Havertown PA 19083