Home Phone# _____________ Cell Phone # __________ Work # __________

Address __________________________________________________________

Mother’s/Guardian Name ____________________________

Father’s/Guardian Name _____________________________

Emergency Contact Person ____________________________ Phone # ____________

Number of years your child has played softball _____Team Last Year ______________

my registration form, as parent or legal guardian of the above registered child, do hereby release and discharge the Lake Placid Youth Baseball League and Dixie Youth Baseball Program from any and all claims arising from my child’s participation in

the program. I understand that this is a physical sport and that I enroll my child to engage in this program at my own risk. Also, I understand that my insurance is the primary carrier for my child’s involvement and any accidents, which might occur, will be taken care of on my health and accident policy. I give my permission to the Lake Placid Youth Baseball, Inc. to use without obligation, photographs, film footage or tape recordings that may include my child’s image or voice for purposes of promotions. I also grant permission to managing personnel or other league representatives to authorize and obtain medical care from any licensed physician, hospital or medical clinic should my child become ill or injured while participating in league activities away from home, or at other times when neither parent/guardian is available to grant authorization for emergency treatment.

Parent/Guardian Signature: ___________________________Date: ________________

We need Coaches and Assistant Coaches. Please check the box if you would consider one of these positions.

Coach_______ Asst. Coach ______

Check your child’s shirt size for uniforms. (Coaches, Asst. Coaches also).

YS 4-6 ____ YM 8-10 _____ YL 12-14 _____

Adult S ____ Adult M _____ Adult L _____ Adult XL ____

This form, your payment and a copy of your child’s birth certificate can be mailed or dropped off at the following locations:

Mailing Address: P.O. Box 1668 Lake Placid, FL 33862

Drop Off: Holiday Inn Express, 608 S. Lakeview Rd Lake Placid

Please make check payable to: Lake Placid Youth Baseball

Registration Fee: $40.00 Ages 7,8 & 9 (League Age is your child’s age as of June 1st 2008). For any additional information, call Heather Carr 465-9187 or Sonja Warner 441-4504.

01/17/07