2012 Fall Soccer Registration Form 2012 Background
Decatur-Adams County Parks & Recreation Youth Soccer Check Form on File ____
School Grades K – 8th For Office Use Only____
Games will be played on Saturdays: September 8th – October 20, 2012
Registration Begins May 1, 2012
Fee: $25.00 (if you sign up and pay by May 25th before 4:00p.m.) after May 25th the fee will be $40.00
Deadline to Register: July 6, 2012 (before 4:00p.m.)
After the July 6th deadline registrations will only be accepted in those divisions where space is
available. There will be a $10.00 late fee added per child and requests will no longer be honored.
Which division will your child play in: Request for same team as sibling _____________________
_____ Decatur Division (if in same age group) Name
______ Monroe Division Please check if your child will be participating in another sport
______ Berne Division during this time. _____ yes _____ no
Please check if child will be available every weekend __yes __ no
Player’s Name _______________________________________Boy____Girl____Phone__________________________
Address____________________________________________City______________State__________Zip____________
Date of Birth:__________________________ Did you play Parks & Recreation soccer last season (2011)? ___yes ___no
School Grade (2012 – 2013)_______________ School:_______________________________________
***Must be enrolled in and attending Kindergarten in fall of 2012 (not Pre-K)
T-Shirt “BUY BIG” – Must fit over sweatshirt. Please circle the size you want.
Youth Medium (10-12) Youth Large (14-16)
Adult Small Adult Medium Adult Large Adult X-Large
I do hereby agree that my child will play with any team to which they are assigned by league officials.
Parent or Guardian Signature ___________________________________________ Date _______________
**Note: If you order the wrong size you will be charged $8.00 to re-order.
If you wish to have your child moved to another team there will be an additional charge of $ 5.00.
(both are payable in advance)
Parent Information:
Father’s Name: _____________________________________ Mother’s: _______________________________________
Address_____________________________________________ Address__________________________________________
City_________________St.______________Zip____________ City__________________St.____________Zip___________
Phone#_____________________________________________ Phone#___________________________________________
Email: ______________________________________________ Email: ____________________________________________
Volunteers – Are required to fill out a Coaches / Volunteer / Instructors background check form.
If you Volunteer Now & Pay by July 6 you will only pay $20.00, after July 6 the fee will be $30.00.
Volunteer’s Name____________________________________ Preferred Phone#______________________________________
Age (if you are a young adult) _______ T-Shirt Size: _____________________
I would like to be a: Head Coach _________ Assistant Coach_____________ Official______________
E-mail Address: _________________________________________________________________________________
All registrations and payments need to be mailed to or delivered to the Decatur-Adams County Parks & Recreation Office
located at Riverside Center, 231 E. Monroe St. Decatur, In. 46733. Phone # 724-2520
**Wavier on back must be signed by a parent or guardian of participant.
ACKNOWLEDGEMENT OF RISKS, LIABILITLY RELEASE AND INDEMNIFICATION AGREEMENT In signing this release for myself and for any named participant(s) (if such participant(s) is under age 18), I acknowledge and understand that, as a participant at the Riverside Center and/or any other facility or program of the Decatur-Adams County Parks and Recreation Department, I/we will be exposed to RISKS of SERIOUS BODILY INJURY, SICKNESS, OR DEATH due to the circumstances inherent in the Decatur-Adams County Parks and Recreation Department such programs, including the negligent acts or omissions of others. I ACKNOWLEDGE that there are a variety of RISKS AND DANGERS inherent in recreational activities and facilities, including but not limited to: sports-related injuries; collisions; falls; risks associated with water-related activities (including diving injuries or drowning); adverse environmental conditions or any other conditions which may cause heat stroke, heat exhaustion, hypothermia or any other illness or injury; physical contact between participants; injuries related to overexertion; slippery floors; misuse or inexperience with fitness equipment. In exchange for being permitted to participate, I voluntarily agree to assume all of these and other risks inherent in participating in such recreational activities and facilities. I acknowledge that I (or the participant for whom I sign, if under 18 years of age) have/has no physical limitations of disabilities of any kind which would restrict me or them from participating. Any special accommodations needed have been noted here_______________________________________________________________.
Despite these dangers, and in consideration of the Decatur-Adams County Parks and Recreation Department accepting my registration, I for myself and /or the participant, all heirs, executors, administrators and assigns, AGREE TO HOLD HARMLESS AND RELEASE the City of Decatur, and Adams County its boards, councils, officers officials, employees, volunteers and other representatives FROM ALL CLAIMS FOR LIABILITY OR LEGAL RESPONCIBILITY FOR ANY DAMAGE OR LOSS OF ANY KIND, including PERSONAL INJURY OR DEATH, PROPERTY DAMAGE, AND ECONOMIC LOSS, arising from my participation in and/or use of the Riverside Center and the Decatur-Adams County Parks and Recreation Department programs and facilities.
I do hereby grant and give the Decatur-Adams County Parks & Recreation Department the right to use my photo or my child’s photograph or image with or without my or my child’s name, both single and conjunction with other persons or objects for any and all purposes including, but not limited to, private or public presentations, advertising publicity and promotion relating hereto. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold the Decatur-Adams County Parks and Recreation Department harmless of and from any and all liability of whatever nature which may arise out of result of such uses. For consideration stated above, I further agree that in the event that my child repudiates or attempts to repudiate such release, I will indemnify and hold harmless the Decatur-Adams County Parks and Recreation Department, its successors and assigns, for any and all loss and damage occasioned thereby.
INSURANCE
All participants are strongly encouraged to be covered by a personal or family medical plan including hospitalization, before they participate in this program. I certify that the applicant is covered by such a plan.
Yes they are covered___________ No they are not____________
CONSENT FOR MEDICAL TREATMENT
I, the undersigned parent or legal guardian of the applicant, do hereby give my permission for emergency medical care to my child by any licensed physician, medical personnel or dentist This medical care may be given under whatever conditions are necessary to persevere the life, limb or well-being of the applicant.
I HAVE READ, FULLY UNDERSTAND, AND AGREE TO THE TERMS OF THIS RELEASE, WAIVER AND INFORMATION.
Date:______________ ____________________________________________________
(Signature of Participant (or Parent or Guardian if Participant in under Age of 18)