The Buckaroo Blog



SMACKOVER YOUTH BASEBALLDear Parents/Guardians, Registration is under way for the 2020 season. Please complete front and back of all registration forms and return in an envelope with Smackover Baseball on the outside and turn into Smackover Elementary Office or the Norphlet Middle School Office. Make sure to include your child’s registration fee. Monday, February 3rd is the FINAL SIGN UP DATE!!!*Please use age chart provided to determine your child’s league age and division.*Concession Stand Workers will be assigned by coaches once the schedule is out. If you cannot work your assigned time please make arrangements to have someone there. If we have no workers, we will have no concession stand. *Coach Pitch will be taking the place of pitching machine this season.Registration Fees per Division:T-Ball (4-6 Year Olds) $ 60.00 per childCoach Pitch (7-8 Year Olds) $ 70.00 per child9-10 Year Olds $ 70.00 per child11-12 Year Olds $ 70.00 per child.Families with more than one child in T-Ball will pay $50.00 per childFamilies with more than one child (in Pitching Machine, 9-10 & 11-12 year old) will pay $60.00 per childFamilies with one in each (example: T-Ball player & 9-10 year old player) will pay $50.00 + $60.00 = $110.00 The Smackover Youth Baseball Program is a VOLUNTEER organization and we will need help for field work days, field preparation prior to each game, and clean up afterwards. If you would like to Coach, please let us know when you register your child. We cannot STRESS enough that we need EVERYONE’S help this year to keep Smackover Youth Baseball Program thriving and active. Thanks in advance for all that you do for this program. Thanks, Smackover Youth Baseball Board Members Smackover Youth Baseball Registration FormPlayer InformationPlayer Information-12700-3429000039338256096000Player Name: Birthdate: League Age: 4930775869950058959758699500Address: Gender:Male FemaleCity: League Fee: ________Division: Please check below State: ______________ Zip Code: _________________ ___ T-Ball ___ Coach Pitch ___ 9-10U ___ 11-12UPhone: Email: Jersey Size: _____ Youth XS (If Available) _____ Youth Small _____ Youth Medium _____ Youth Large _____ Adult Small _____ Adult Medium _____ Adult Large63504826000-63576200Medical Release00Medical ReleaseParent (s)/Guardian Name:____________________________________ _ Relationship:____________________________Parent (s)/Guardian Name:_____________________________________ Relationship:____________________________In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified EmergencyPersonnel. (i.e. EMT, First Responder, E.R. Physician)Family Physician: ____________________________________________ Phone: _________________________________Address: __________________________________________ City:________________ State/Country:_________________Hospital Preference: __________________________________________________________________________________Parent Insurance Co:_________________________ Policy No.:__________________Group ID#:_____________________If parent(s)/legal guardian cannot be reached in case of emergency, contact:___________________________________________________________________________________________________ Name Phone Relationship to Player__________________________________________________________________________________________________ Name Phone Relationship to PlayerPlease list any allergies/medical problems, including those requiring maintenance medications. (i.e. Diabetic, Asthma, Seizure Disorder)Medical Diagnosis:__________________________________________________________________________Medication: __________________________________________________________________________Dosage & Frequency:__________________________________________________________________________Date of last Tetanus Toxoid Booster (If Known):_______________________________________________________________The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.Mr./Mrs./Ms. ________________________________________________________________________________________ Authorized Parent/Guardian Signature Date:314325137795Internal Use Only:Dues PaidYesNoDivision Assigned: _________________________Team Name: _____________________________00Internal Use Only:Dues PaidYesNoDivision Assigned: _________________________Team Name: _____________________________-602488074295Amount: ____________________________Date: _______________________________Amount: ____________________________Date: _______________________________5071110-415290OFFICE USE ONLYDate Paid _____/_____/_____Amount $ ________________Receipt # ________________Member #________________Membership Year _________Initialed _________________00OFFICE USE ONLYDate Paid _____/_____/_____Amount $ ________________Receipt # ________________Member #________________Membership Year _________Initialed _________________2258060-41783000-280035-284480MEMBERSHIP FEES ARE NON-REFUNDABLE00MEMBERSHIP FEES ARE NON-REFUNDABLE Boys & Girls Club of El DoradoMEMBERSHIP REGISTRATION FORM(PLEASE PRINT)Child’s Name ____________________________________________________Mailing Address ____________________________________________________________City _________________________ State _________________ Zip Code ______________Home Phone __________________________ Date of Birth ________________________ (mm/dd/yyyy)-95251504950060960014732000 Male Female Grade ____ School _________________________________________ E-Mail Address: _________________________________________________________________________Emergency Contact _______________________________________________________________________Emergency Contact Relationship _________________________ Contact’s Phone # _________________________Ethnicity3780155279400027628852286000162115522860001905-63500 African American Caucasian Hispanic Multi-Racial-10795141605001419225317500 Native American Other ________________________________ Household 2326640127000-101606985001207770889000 Single Parent Both Parents GuardianName of Person Living With _________________________________________________________________Father’s Name____________________________________________________________________________(Stepfather, Grandfather, Guardian)Employed By_______________________________________________________________________________3134995317500198247019050013506451905006731001016000Military Yes No Active Duty Reserve Duty Branch ________________________Work Phone # ____________________ Home Phone # _____________________________________Mother’s Name ____________________________________________________________________________(Stepmother, Grandmother, Guardian)Employed By_________________________________________________________________________3136900114300019843751143000128460527305006705604699000Military Yes No Active Duty Reserve Duty Branch _____________________________Work Phone # ____________________ Home Phone # _____________________________________RELEASE FORMI declare that I am the parent or legal guardian of the minor listed below. To the best of my knowledge, my child is in good health and adequately immunized to participate in the Boys & Girls Club activities.In the event that my child is injured I hereby authorize his/her athletic supervisor, coach or any other Boys & Girls Club of El Dorado employee to secure necessary treatment for my child. I further acknowledge that I will be responsible for any medical or hospital fees cost associated with my child’s medical treatment. If possible, confirmation of this authorization should be made with me prior to treatment by calling me at the listed phone number. In case I cannot be reached for an emergency you may proceed with treatment without further authorization.I understand that the Boys & Girls Club of El Dorado is NOT A DAYCARE and the “open door” policy that allows children to come and go, as they desire. I understand also that the Club accepts no responsibility for keeping my child in the building or on the premises.I hereby give permission for a photo or likeness of my child to be used in brochures and other promotional materials produced by the Boys & Girls Club of El Dorado. The photo will not be sold without the express written consent of the parent or legal guardian.Data Collection Permission:I give my permission to the Boys & Girls Club of El Dorado to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, Boys & Girls Clubs of America (BGCA), funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members. Data Sharing Permission: I understand that the Boys & Girls Club of El Dorado may share information about the minor child listed on this application with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by Boys & Girls Club of El Dorado, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential. I agree that this waiver is valid as long as my child is a member of the Boys & Girls Club of El Dorado.Child’s Name ________________________________________________________Parent/Guardian Signature ______________________________________________Date _____/_____/_____ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download