REGISTRATION / MEDICAL RELEASE

GEORGIA YOUTH ATHLETIC ASSOCIATION

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Georgia Youth Athletic Association Registration Form
P.O. Box 1234 Covington, GA 30016   Website: www.GAyouth.org     Email: registration@GAyouth.org
Section A: Parent Information
Parent/Legal Guardian 1
First Name Last Name Relationship
     
Home Phone Cell Phone Work Phone
     
E-mail Address  
Parent/Legal Guardian 2
First Name Last Name Relationship
     
Home Phone Cell Phone Work Phone
     
E-mail Address  
Section B: Child's Information
First Name Last Name Date of Birth Grade
       
Home Street Address City  Zipcode
     
School Name  
Section C: Payment Information
Registration Fees
Football Select Payment Method
New $185  
VISAMastercardCash Amount: Check Number/Amt:
 
Returning $155   Card Number and Exipration Date:
Cheerleading   Refund:  All participants who request, in writing, a refund of their application fee prior to the first practice for their team will receive a full refund less $50.00 for handling costs.  After the start of the first practice there will be no refunds. All refunds are contingent upon the return, in good condition, of all equipment.  Refunds will be mailed no less than 3 weeks after the request for a refund has been received.
New $100  
Returning $65  
Equipment Information
Equipment:  Each participant will be loaned the following equipment:  A helmet with face mask and chin strap, shoulder pads, hip/thigh/knee pads, game pants, practice pants and jersey, and game and practice belts. The Game Jersey will have the participants name on it and therefore be kept by the individual.  Players should provide their own shoes, which should be all-purpose football/soccer shoes with molded sole rubber cleats.  Metal cleats or removable cleats are not permitted.
Each player:  Is expected to clean on a regular basis and return all loaned equipment at the end of the season.  Players should notify their coach immediately if any equipment is damaged or lost during the season, so it may be replaced.  Replacement costs will be assessed to each player for lost equipment.  The amounts will be as follows:  helmet $120, game pants $40, shoulder pads $65, practice jersey & pants $45, belts $10, rib pads $25, girdle and pads $32, thigh/knee pads $15. Total = $ 352.00.
Parent/Guardian Permission
I the parent/guardian of the above named participant hereby give my approval for participation in any and all of the activities of the Georgia Youth Athletic Association during the season.  I assume all risks and hazards, incidental to the conduct of any of the activities, including transportation to and from such activities.  I do further release, absolve, indemnify and hold harmless the Georgia Youth Athletic Association, its organizers, sponsors, directors and supervisors, and any or all of them, in the case of injury to my child.  I hereby waive all claims against the organizers, sponsors, directors and supervisors appointed by GYAA.  I likewise waive, to the extent not covered by liability insurance, any claim against any person transporting my child to and from the activities.
Parent/Guardian Signature Date Parent/Guardian Signature Date
       

 

GEORGIA YOUTH ATHLETIC ASSOCIATION

 ASSUMPTION AND ACKNOWLEDGMENT OF RISKS

AND

RELEASE OF LIABILITY AGREEMENT

In consideration of being allowed to participate in any way for the Georgia Youth Athletic Association, its related events and activities, the undersigned, acknowledges, appreciates, and agrees that:

  1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
  2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
  3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will bring such to the attention of the nearest official immediately; and
  4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS the Georgia Youth Athletic Association its officers, officials, agents and/or employees, other participants sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event ("Releases"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

__________________________________________

PARTICIPANT’S NAME

X______________________________________ Age: ____ Date Signed: ________________

PARTICIPANT’S SIGNATURE

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE

(UNDER AGE 18 AT TIME OF REGISTRATION)

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releases, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releases from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.

X_____________________________________ ______________________________

PARENT/GUARDIAN’S SIGNATURE PARENT/GUARDIAN’S NAME

 

 

 

 

MEDICAL RELEASE

GEORGIA YOUTH ATHLETIC ASSOCIATION

2010 MEDICAL RELEASE

 

I hereby release __________________________________________to play for the Fall 2010 football season.

List any Allergies or Other Medical Condition:

 

 

Doctor/ Nurse Practitioner Name (please print) ______________________

Doctor/Nurse Practitioner SIGNATURE*___________________

Doctor/ Nurse Practitioner Phone ______________________________

 

Date ____________________________________

*NOTE: This form needs to be physically signed by a Doctor or Nurse Practitioner. A stamped signature will NOT be accepted. This form must be turned into the appropriate coach/Team Parent BEFORE a player can receive any equipment and participate in practice. A fax or copy of the original will be accepted.

 
I understand all of the above information to be accurate. I, as parent/guardian of said GYAA player hereby give permission for said child to participate in any and all activities sponsored by Georgia Youth Athletic Association.

 

Parent / Guardian (please print) ______________________________

 

Parent / Guardian (signature) ________________________________

 

Date______________________________________________________