EmailMe Form - SHELBY YOUTH SPORTS, INC.

Gender

MALE

FEMALE

Participant's Name

First Last

Birthday

MM / DD / YYYY

Age

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

School Attending

Parent or Guardian

First Last

Email

My Child has Sufficient Coverage

Sport

Track

Football

Cheerleading

Area Playing For:

Bantam

Peewee

Junior

Senior

Child Participated SYS Last Year Area

Football
Track
Cheerleading

List any Physical liabilities (you may be required to supply a medical release form)

Doctor's Signature

Clear

Emergency Contacts

	Name	Contact Number
Contact #1
Contact #2

In consideration for my child being permitted to participate in the recreational activities sponsored by Shelby Youth Sports and the Associations Areas, I hereby agree to assume all risks and responsibilities relative hereto.  I give consent for all medical care to be given to the above athlete as may be deemed advisable by a duly licensed Doctor of Medicine, to preserve the health and well being of the athlete.  I agree to hold harmless, defend, release and forever discharge Shelby Youth Sports, the Association’s Directors, Memphis City Schools, Shelby County Schools, Millington NSA, Tipton County Schools, Munford Parks and Recreation, Haywood County and/or any private facility, its directors, officers, agents, employees and volunteers, from and against any and all claims or liability due to any injuries, damage to property or death which may result from any participation in the Associations recreational activities.  I understand that the insurance coverage included as part of my child’s registration fee is supplemental to my own coverage.  I also agree to abide by and be bound by the Constitution, rules and bylaws of this Association.

Parent/ Guardian Signature

Clear

Date

MM / DD / YYYY

EXEMPTION

	Approved
Team Area Requested
Assigned Team Area
Reason

For SYS Use Only

Birth Certificate Number
Weight