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www.coloradovolleyballconnection.com
2007
Summer Youth Volleyball Program Registration Form - Anderson Recreation
Center, Wheat Ridge CO
Circle one: 10-13
years old: Tuesdays 6-7:30 PM & Saturdays 12-2
PM & 14-17
years old: Tuesdays 7:30-9 PM & Saturdays 2- 4
PM
*note: if you feel your child should be in a different age group, we will work
with you to ensure they are playing at the correct skill level regardless of
their age.
SPORT:
Volleyball Name
of player ____________________________________________
Nickname?_________________________ Player’s Age ________
Birth date:
______/______/__________-check one: Male ____ Female ____ School Grade _______
Height ____________ Weight ________
T-shirt Size: Youth
Small Medium Large Adult
Small Medium Large XL XXL
Child’s Volleyball
experience/years
played:_________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
Medical
Allergies, medical conditions or medications we should be aware of? If yes,
please explain
-_____________________________
______________________________________________________________________________________________________________________________________________
Parent/Guardian (s) Information:
1-__________________________________________
Phone #(s)_______________________ (C)_________________________(B)_________________________
2-__________________________________________
Phone #(s)_______________________ (C)_________________________(B)_________________________
Address: _______________________________________________________________________City____________________________Zip
______________
Email
Address(s):
_________________________________________________________________________________________________________________
In case of emergency:
Family Doctor_____________________________________________________Phone:_______________________________________
Hospital
Preference(s)
1)_____________________________________________________2)_____________________________________________________
*Who, if anyone other than a
parent or guardian listed above, has your, permission to pick up your child
from this program each day?
(1)
_______________________________________________________________ Phone(s)____________________________________________________________________
(2________________________________________________________________ Phone(s)____________________________________________________________________
Please note that this person must
have I.D. on them for your child to be released into their care. If there is an
emergency or an unidentified person attempts to pick up your child, we will keep
them in our care until which time we can return them to you safely.
Any
specifics/strengths/weaknesses you feel we should be aware of to help us make
this a positive experience for you child? * (Use back of this form for more
space if needed.)
_____________________________________________________________________________________________________________________________________________
Release & Waiver: Although
supervised athletics and programs for both adults and youths which involve
activity are not considered to be hazardous, the potential for injury is present
due to the nature of these athletic activities. I, as the above mentioned parent
or legal guardian of the above mentioned youth enrolled on this form; hereby
release, discharge and covenant not to sue The Colorado Volleyball Connection,
Inc. and any of it’s employees or volunteers should there be injury to my child
while participating in the sports activities sponsored by the aforementioned. I
also acknowledge he nature of the sport to have the potential to cause injury
and voluntarily accept al risks in that respect. As parent/guardian, I release
the Colorado Volleyball Connection, Inc. of any claims, judgments or expenses
that the person named on this form may incur by virtue of my/their activities or
presence in the facility in which this sport will be practiced, taught or
performed. I fully understand that the aforementioned does not provide any
accident or health insurance coverage for my child.
I hereby authorize The Colorado
Volleyball Connection, Inc. to take my child to the above named physician or
medical treatment facility in the event of an emergency in which neither
parent/guardian can be reached. I hereby authorize any licensed physician or
medical treatment facility to treat my child in case of an emergency in which
the above named physician can not respond. I hereby state I have provided all
pertinent medical background information about my child, that would be needed in
the event of an emergency, on this form.
I hereby grant full permission
that my and/or my child’s image/photographs, videotapes and/or record of this
program may be used for any purpose seen fit by The Colorado Volleyball
Connection, Inc.
Parent or Guardian Name (please
print)
_________________________________________________________________________________
Parent or Guardian signature
_______________________________________________________Date_______________________________
Please mail to: The Colorado Volleyball Connection - P.O. Box 1682 - Arvada,
CO 80001 *
www.coloradovolleyballconnection.com * 303.456.4544
If choosing to pay by Credit Card, you may pay via Paypal to:
coloradovolleyballconnection@comcast.net, and add $5 per $100 processing
fee. Paypal is a secure online solution for credit card banking.
