Flag Football 2014

724-981-3700

Now offering co-ed soccer for children Registration & Emergency Medical Form www.buhlcommunityreccenter.com NO REFUNDS

Player Last Name________________________________First Name________________________________ Grade_________ Address_________________________________City_____________ ___________State____________Zip__________ Birthdate________________ Age_________ Sex M F Home Phone_______________________ Cell_____________________ If ok to text messages YES_____ NO_______ Email_______________________________________________________________ Mothers Name_________________________ Fathers Name_______________Guardian Name___________________ Please make checks payable to (BCRC) Buhl Community Recreation Center 28 Pine Ave., Sharon, PA 16146 by Jan.31st. Paid_________________________ Check #_____________________T-SHIRT Size YS YM YL AS AM AL AXL IMPORTANT INFORMATAION I, the parent/guardian of the above name player, a minor, agree that the player will abide by the rules and regulations of the BCRC, its affiliated organizations and its sponsors. In consideration of the players participation in the BCRC Flag Football program. I, for myself, and player, and respective heirs, administrators, and successors intending to be bound, hereby release, discharge and/or indemnify the parties, (including the BCRC and (the owners and operators of the facilities used for the programs, and their respective, directors, officers, employees, agents and representatives as from and against all claim, liabilities, damages or causes of action arising out of or in connection with the players participation in the programs including, without limitations players transportation, to and from any program, with transportation is hereby authorized). I further attest that I have my own health and injury insurance; further, I understand that BCRC are secondary in nature, and are not meant to replace or supplement my own insurance. Please NOTE by signing this, you certify that you currently have your own health insurance, and understand that BCRC only provides secondary insurance. NAME_______________________________________________ Parent/Legal Guardian (PLEASE PRINT) SIGNATURE________________________________________________DATE____________________________

Are there any Allergies, Medical Problems or Medications that the BCRC and/or Medical Personnel should be informed about? Yes________________________ No________________________ If yes please explain: 1. I hereby give my consent permitting the BCRC personnel to apply First Aid Treatment until the family doctor can be contacted Yes__________________ No_____________________ 2. In the event the designated preferred practitioner is unavailable I hereby give my consent to the BCRC personnel to secure another licensed practitioner. Yes_____________________ No___________________ 3. I hereby give my consent to the BCRC personnel to secure ambulance service and transfer the player to _______________(preferred hospital)or any reasonable accessible hospital. Please contact Buhl Community Recreation Center for further question. 724-981-3700

PLAY ALL 3 AND GET A DISCOUNT (TRIPLE PLAY PRICING)

Members Fee $29.00 (Triple play $79.00) Non- Membership Fee $ 39.00 (Triple Play $99.00)