CBYSA MEMBERSHIP FORM
Team Name:
_______________________________________________________________________
Coaches Name:
_____________________________________________________________________
Age Group: Under
________________ Boys/Girls _________________
PLAYER INFORMATION
First Name:
_____________________________________________ Middle Initial: _______________
Last Name:
_____________________________________________ Male/Female: _______________
Address:
___________________________________________________________________________
City:
(
Players Date of Birth
(MM/DD/YYYY): _________________________________________________
Mothers Birthday (MM/DD):
_________________________________________________________
Mothers Name:
_____________________________________________________________________
Fathers Name:
______________________________________________________________________
Home Phone: (________)_________________Cell Phone:
(________)_________________________
EMAIL Address:
____________________________________________________________________
List any Medical problems or
prohibition player has ________________________________________
Person to notify in emergency
______________________________ Phone ______________________
Doctor to notify in emergency
______________________________ Phone ______________________
As the parent or legal
guardian of the above named player, I hereby give consent for emergency medical
care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry.
This care may be given under whatever conditions are necessary to preserve the
life, limb or well being of my dependent.
Signature of Parent or
Guardian
X
________________________________________________________________________________
Address:
___________________________________________________________________________
City/State:
_________________________________________________________________________
Phone: (________)______________________ Cell:
(_______)________________________________