SILVER HAWKS REGISTRATION FORM

__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Registration (Please Print)

Name________________________________________ Grade (Next school year 12) ________

School you will be attending 2012: ________________________________________

Address_______________________________________City____________________Zip_________ Home Phone_______________ Emergency Phone____________  Cell Phone _________________

Parent Email__________________________ Player Email_________________________________

Have you ever played Field Hockey? ____Yes ___ No. Years played:___  Do you have your own stick? ___Yes___ No Are you interested in being a goalie?___ Yes ____ No

____Yes, I am interested in ordering a stick with other members of this team. (Sticks available through coach.) We will email you with additional information on Stick Orders.

   
*****************************************************************************************************************************

Parents! The waiver of liability and emergency treatment portions of this form must be signed in order for your child to participate. EMERGENCY MEDICAL AUTHORIZATION PART 1 AND PART 2 OR 3 MUST BE COMPLETED. Please PRINT

Student’s Name:________________________________________________________________

1.Waiver of Liability

The user assumes and accepts full responsibility for any and all personal liability claims arising from the activity.  __________________________ assumes and accepts full responsibility for any and all liability claims arising from this activity, and releases the Liberty Athletic Boosters and any coaches or instructors from liability for any accident, death or other catastrophe.

Parent/Guardian Signature____________________________ Date__________

2. Consent to Emergency Treatment

In the event that reasonable attempts to contact me at ________________ or ______________ (other parent) have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by Dr._________________ (preferred physician) ___________(phone)or Dr.______________ (preferred dentist)______________(phone), or in the event that the designated preferred practitioner is not available, by another licensed physician or dentist, and (2) the transfer of the child to _______________ (preferred hospital) or any hospital reasonably accessible.

Known Allergies: Current Medications:__________________________________________________

Health Concerns (Diabetes, Asthma, Bee Stings, Etc. _____________________________________

Physical Impairments: Date of Last Tetnus Booster:______________________________________

Parent/Guardian Signature ____________________________ Date:_______________

3.         Refusal to Consent

I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the camp authorities to take no action except to contact:_______________________ Phone: ________________________.

Parent/Guardian________________________________ Date:__________

Deadline for registration is May 30, 2011.

Send this form and a check of $135.00, payable to "Liberty Athletic Boosters" Attn: Silver Hawks Field Hockey, Christina Hunter, 8211 Glenmore Drive, Powell, Ohio 43065.