CYO REGISTRATION
Circle: Baseball Basketball
Cheerleading Football Soccer Softball T-Ball Track
You will NOT be
allowed to participate unless this form is PROPERLY and COMPLETELY
filled out by the assigned due date !!
PARTICIPANT
INFORMATION/MEDICAL EMERGENCY FORM Grade
_____________
Participant’s
Name ____________________________________________ Date of Birth _____________________
Name
of Parent/Guardian/Custodian
________________________________________________________________
Address
_______________________________________________________________________________________
Home Phone ________________ Father’s Work Phone ___________________ Mother’s Work Phone _____________
If
the child has any ongoing medical problems, please indicate
_____________________________________________
If
the child is currently taking any form of medication, please indicate type of
medication/frequency _______________
________________________________________________________________________________________________
Name
of child’s physician ______________________________________ Physician’s Phone
____________________
I
hereby authorize the coach accompanying the CYO team to seek immediate medical
treatment for my child listed above, if a medical emergency arises while on the
way to, returning from, or during any practice, game, or meet in which the team
participates. I also authorize the
attending physician to perform any emergency treatment necessary, after
consultation with the coach if I cannot be reached.
Date
_______________ Signature
of Parent/Guardian/Custodian _______________________________________
PARISH
COPY To be kept with each CYO coach
in the event of an emergency.
CYO
COPY To be turned into the CYO Office
Name
___________________________________________________ Birthdate _________/ _________/ _________
Month Day
Year
Address
_____________________________________________________ Home Phone
_______________________
_____________________________________________________________
Zip Code _________________________
Parish
Playing For ___________________________________ Social Security No. ________ ______ ________
Home
Parish
____________________________________
School attending
__________________________
Catholic ( ) Non-Catholic ( ) Male ( ) Female ( ) Grade __________________
WE,
THE UNDERSIGNED, UNDERSTAND ALL THE RULES OF ELIGIVILITY IN TH ECYO LEAGUE AND
WE ARE AWARE OF THE PENALTIES THAT COULD BE PLACED ON A PARISH, TEAM, PLAYER OR
COACH OF THE RULES OF ELIGIBILITY ARE BROKEN.
WE CERTIFY THAT ALL INFORMATION LISTED ABOVE IS CORRECT.
____________________________ ______________________________ ______________________________
Coach’s
signature Participant’s signature Parent/Guardian/Custodian
signature
The
parent, guardian, or custodian by executing this registration for and on behalf
of the named participant represents and warrants that they are unaware of any
physical or mental impediment that would or could cause injury or harm to the
participant or to others by the said participant’s participation in the
activities of the Catholic Youth Organization (CYO). Due to the strenuous nature of some activities, the parent,
guardian, or custodian is urged to consult a physician concerning the fitness
of the participant to engage in CYO activities prior to executing this
registration. Since all activities
present certain inherent and/or inadvertent risks and hazards, known and
acknowledged by the undersigned, they, parent, guardian, or custodian, by their
execution hereof, approve the participant’s participation and assume all
liability incident to the said minor’s participation, except that liability,
which is imposed by law, o the Catholic Archdiocese of Washington, the Catholic
Youth Organization, their employees, agents, or volunteers.
Date ______________________
_____________________________________
Parent, Guardian, or Custodian Signature
revised
August 1995