Southampton Township Recreation Association

REGISTRATION FORM

PO BOX 2204, Southampton, NJ 08088

PLEASE DO NOT WRITE IN GRAY SHADED AREAS

SPORT DIVISION SEASON SHIRT SIZE

LAST NAME FIRST NAME MIDDLE INIT.

DATE OF BIRTH AGE on 04/30

ADDRESS: HOME PHONE

GRADE

SEX

NAME OF PARENTS/GUARDIANS

EMAIL ADDRESS___________________________

MEDICAL INFORMATION

I HEREBY AUTHORIZE ANY COACH, OR STRA REPRESENTATIVE TO CONSENT TO ANY MEDICAL / SURGICAL / DENTAL TREATMENT, X-RAY, ANESTHETIC, OR HOSPITAL CARE ON THE ADVICE OF ANY PHYSICIAN / SURGEON / DENTIST LICENSED IN THE STATE OF NEW JERSEY. IN THE EVENT OF INJURY, SICKNESS OR OTHER EMERGENCY INVOLVING THE MINOR CHILD NAMED ABOVE WHILE I AM NOT PRESENT. I HAVE LEGAL CUSTODY AND AUTHORITY TO GRANT SUCH PERMISSION AND ASSUME RESPONSIBILITY FOR PAYMENT. I UNDERSTAND THAT PRIMARY MEDICAL INSURANCE IS MY RESPONSIBILITY; INSURANCE CARRIED BY STRA WILL BE SECONDARY. OTHER THAN AS STATED BELOW, I HAVE NO KNOWLEDGE OF ANY MEDICAL CONDITIONS THAT PRECLUDE OR ENDANGER THE CHILD PARTICIPATING IN THIS ACTIVITY. IF CHILD IS CURRENTLY UNDER A DOCTOR’S CARE I WILL CONSULT PHYSICIAN PRIOR TO PARTICIPATION.

EMERGENCY CONTACT RELATIONSHIP

EMERGENCY PHONE PARENTS WORK PHONE

INSURANCE CARRIER POLICY NUMBER

MEDICATIONS

EXISTING MEDICAL CONDITION OR ALLERGIES

VOLUNTEER INFORMATION

STRA IS AN ALL VOLUNTEER ORGANIZATION AND WE NEED YOUR HELP. PLEASE CHECK AT LEAST ONE AREA OF INTEREST TO AN ADULT IN YOUR FAMILY, OR WE WILL ASK YOU TO ASSIST WHERE MOST NEEDED.

ÿ COACH ÿ ASSISTANT COACH ÿ COMMISSIONER

ÿ PUBLICITY COMMITTEE ÿ FIELD MAINTENANCE ÿ CONCESSION STAND

ÿ UMPIRE / REFEREE ÿ FUND RAISING ÿ ADMINISTRATIVE

ÿ SPONSOR COMMITTEE ÿ OTHER

SPONSOR INFORMATION

NAME OF COMPANY

NAME OF PERSON TO CONTACT

PHONE:

I approve the participation of the above named child in STRA activities for the named season and assume all risks incidental to such activities. I release, absolve, indemnify and hold harmless STRA, its agents, representatives, and sponsors, any and all of them. In case of injury I waive all claims against the organizers and supervisors appointed by them. I will produce Child’s Birth Certificate if requested. I agree to be held responsible for the return of any issued uniform or equipment in good, clean condition immediately at the conclusion of the season. I will be held liable for the cost of any uniform not turned in, and acknowledge that my child will not be assigned to any other team in the future until payment is made.

Parent/Guardian Signature __________________________________ _ Date: __________ _____

REGISTRATION FEES ARE NOT REFUNDABLE EXCEPT FOR MEDICAL REASONS.

Cash Check # ________________ Registration Fee Late Fee

Fund Raiser Other Received By