Pecatonica Sports Association 2009 Baseball / Softball Registration Form

Name: __________________________________________________________ Please Circle: Male / Female

Address: _____________________________________________________________________________

Date of Birth: ____________________________ Grade Entering in Fall 2009: _____________________

Current School: ________________________________________________________________________

Mother’s Name: ___________________________ Phone # __________________Cell# ______________

Mother’s Address if different than above: __________________________________________________

Mother’s E-Mail Address : _______________________________________________________________

Father’s Name: ___________________________Phone # _________________ Cell# ________________

Father’s Address if different than above: ___________________________________________________

Father’s E-Mail Address: ________________________________________________________________

Shirt Size: YOUTH – S – M – L ADULT – S – M – L - XL Registration Fee: $60.00

Age Deadline is May 1st

Medical Release

I, parent or guardian of (player’s name)________________________________, hereby give approval for participation in any and all

Pecatonica Baseball league activities. I hereby grant permission to managing personnel or other league representatives to authorize and

obtain medical care from any licensed physician, hospital or medical clinic should the player become ill or injured while participating in league

activities when neither parents nor guardian is available, either in person or by phone, to grant authorization for emergency treatment. I

assume all risks and hazards incidental to such participation, including transportation to and from the activities: and, do hereby waive, release,

absolve, and indemnify and agree to hold harmless the Pecatonica Sports Association, Pecatonica Baseball League, the organizers,

sponsors, supervisors, participants, and persons transporting the player to and from activities, for any claim arising out of an injury to the player.

SPECIAL NOTE: Please indicate any special needs of the player being registered that would be necessary or helpful to know in the event of

an emergency (ie: allergies, special medications, other conditions that are vital to medical care.)

Player Allergies: _______________________________________________________________________

Other Medical Information: ______________________________________________________________

Parents/Guardians Signature: ___________________________ Relationship: _____________________

Date: ________________________________

If you are interested in Coaching or Managing a team, please contact John Blassingham, by phone or email.

If you have any concerns regarding your player’s Coach, Manager or teammates, please contact John Blassingham, byphone or email • (815) 621-3418 • JBlassingham@verizon.net

All coaching requests and special player requests will be reviewed by the Pecatonica Sports Assoc. Board