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Lake City Ball Club
4th, 5th & 6th Grade Clinic
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Participant Information
(Required.)
Full Name:
DOB:
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Gender:
(Required.)
Male
Female
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Grade Level:
(Required.)
4th Grade
5th Grade
6th Grade
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Select any medical conditions or allergies the participant has (Select all that apply)
(Required.)
Asthma
Diabetes
Allergies
None
Other
If Yes to above please provide further information
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Parent/Guardian Information
(Required.)
First & Last Name:
Phone #:
Email Address:
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Permissions:
(Required.)
Do you consent to emergency treatment for participant if necessary?
Yes
No
Do you consent to participant's photo being taken for promotional purposes?
Yes
No
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I acknowledge, as the parent/guardian of the above named child, do hereby give my consent for my child to participate in the LCBC 5th & 6th Grade Clinic. I will not hold LCBC, coaches, teams, trainers sponsors or anyone associated with the league responsible for any claims including but not limited to, injuries that may happen to my child while participating in the league. I also understand all ball games can involve contact and/or injury to my child and I will not hold LCBC accountable for any injury incurred. I will be responsible for any LCBC equipment issues to me or my child, for any product or funds raised or distributed on behalf of LCBC.
(Required.)
Yes
Submission of this form constitutes my digital signature as the legal Parent/Guardian of participant on information stated above. I will re-attest my agreement and consent upon check-in on the day of clinic.
Signature
Date:
