REGISTRATION FORM

 

__  Fall Soccer   __  Flag Football     __  Tackle Football            __  Volleyball         __  1st/2nd Basketball __ Basketball    __  Spring Soccer  __  Baseball/Softball/Coach-Pitch/Tee Ball

 

  PLEASE FILL OUT THE FOLLOWING SECTION WITH THE PLAYER’S INFORMATION 

Ethnicity (These are the classifications used by the State of Oregon)
__  Am. Indian/Alaskan Nat.    __  Asian/Pac. Islander  __  African Am.  __  Hispanic  __  Unknown/Unspecified  __  Caucasian 

Last Name______________________________________ First Name_______________________________
Birth Date ____/____/_______ Gender o M o F Grade_________ School __________________________
         Home Address___________________________________________ City______________________ Zip________
Home Phone (_____)_________________ Email Address __________________________________________

Mother/Guardian_____________________________________            Work Phone (____)___________________
Employer___________________________________________           Job Title____________________________

Father/Guardian _____________________________________             Work Phone (____)___________________
Employer___________________________________________           Job Title____________________________

Emergency Contact (We will only use this number if we cannot reach either parent/guardian)
Name_____________________________________________            Phone #(_____)_____________________

FEES:
Regular registration fee $_______________                       Does the participant need any accommodation for a
                                                                                                         disability? Please contact a customer service
                                                                                                         representative and we will make every effort to
(less scholarship discount) $(______________)                                make accommodations.
(less $5.00 coupon*) $(______________)
(less OTHER discounts) $(______________)                         Please check one of the following boxes:

Registration Amount $_______________                           □ Information is to be used only for KIDSPORTS business

OTHER:
Late Fees $(______________)                                                 □ KIDSPORTS may release information to other organizations
Coupon Book* $_______________

My Charitable Gift to the
Emerald KIDSPORTS
Scholarship Fund $_______________

TOTAL CHARGES $_______________

I have read and agree to the permission to play on the reverse side of this form. 

___________________________________________________                          ___________________
Signature of Parent /Legal Guardian                                                                                    Date

 

Please complete the information below if you wish to pay with credit card. We accept VISA and Mastercard.

 

Credit Card Number __________ __________ __________ __________ Expiration Date______/______

                                                                  (XXXX          XXXX             XXXX          XXXX)

 

OFFICE USE ONLY Date_____/_____/_______    Amount Paid $__________                    Receipt # ___________________ Team Assignment _______________________    Deferred Amount $_____________________    3rd Child    Coach’s Coupon     KS Coupon    Approved Special Discount per ____    Scholarship    Raves    Transfer Request    School Coordinator

As parent/guardian I release above named child to participate in current KIDSPORTS program.  I release KIDSPORTS/agents from any liability for injury resulting from participation.  I will reimburse KIDSPORTS for any unreturned equipment/gear.

                I agree to abide by and uphold KIDSPORTS rules, policies and procedures, including but not limited to the KIDSPORTS harassment policy, to respect the decisions of coaches and officials made in the course of performing their duties and to assume full responsibility that the child I am registering and all of our family members and guests do the same.  I acknowledge that if I fail to do so, the child I am registering fails to do so, or any of our family members and guests fail to do so, I, the child and/or, any of our family members or guests may be removed and barred from any and all KIDSPORTS practices and events, that the child I am registering may be removed from the KIDSPORTS program, that I may be barred from registering children for any future KIDSPORTS activities and that the child I am registering may be barred from registering for any future KIDSPORTS activities.  I also agree that KIDSPORTS’ dispute resolution and arbitration procedures are the sole and exclusive means for finally resolving any and all disputes with KIDSPORTS, including, but not limited to claims arising out of federal and state discrimination laws.  I understand and I am giving up any right I might otherwise have to present disputes to a court and receive protections available in traditional court proceedings.  I understand that I may review a current copy of all applicable rules, policies and procedures any weekday during KIDSPORTS regular working hours at its business location.