8/13/2019 Flag Football Registration

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Now offering co-ed soccer for children724-981-3700 www.buhlcommunityreccenter.com

PlayerLast Name________________________________First Name________________________________ Grade_________Address_________________________________City_____________ ___________State____________Zip__________Birthdate________________ Age_________ Sex M F Home Phone_______________________

Cell_____________________ If ok to text messages YES_____ NO_______Email_______________________________________________________________Mothers Name_________________________ Fathers Name______________ _Guardian Name__________________Please make checks payable to (BCRC) Buhl Community Recreation Center 28 Pine Ave., Sharon, PA 16146 byan.31 st.

Paid_________________________ Check #_____________________T-SHIRT Size YS YM YL AS AM ALAXL

Are there any Allergies, Medical Problems or Medications that the BCRC and/or Medical Personnel should be informed about?Yes________________________ No________________________ If yes please explain:

1. I hereby give my consent permitting the BCRC personnel to apply First Aid Treatment until the family doctor can becontacted Yes__________________ No_____________________

2. In the event the designated preferred practitioner is unavailable I hereby give my consent to the BCRC personnel tosecure another licensed practitioner. Yes_____________________ No___________________

3. I hereby give my consent to the BCRC personnel to secure ambulance service and transfer the player to _______________(preferred hospital)or any reasonable accessible hospital.

Please contact Buhl Community Recreation Center for further question. 724-981-3700

PLAY ALL 3 AND GET A DISCOUNT (TRIPLE PLAY PRICING)

Members Fee $29.00 (Triple play $79.00)

Non- Membership Fee $ 39.00 (Triple Play $99.00)

Flag Football 2014Registration & Emergency Medical Form

NO REFUNDS

IMPORTANT INFORMATAION

I, the parent/guardian of the above name player, a minor, agree that the player will abide by the rules andregulations of the BCRC, its affiliated organizations and its sponsors. In consideration of the players participation in

the BCRC Flag Football program. I, for myself, and player, and respective heirs, administrators, and successorsintending to be bound, hereby release, discharge and/or indemnify the parties, (including the BCRC and (the ownersand operators of the facilities used for the programs, and their respective, directors, officers, employees, agentsand representatives as from and against all claim, liabilities, damages or causes of action arising out of or inconnection with the players participation in the programs including, without limitations players transportation, to

and from any program, with transportation is hereby authorized). I further attest that I have my own health andinjury insurance; further, I understand that BCRC are secondary in nature, and are not meant to replace orsupplement my own insurance. Please NOTE by signing this, you certify that you currently have your own healthinsurance, and understand that BCRC only provides secondary insurance.

NAME_______________________________________________ Parent/Legal Guardian (PLEASE PRINT)SIGNATURE________________________________________________DATE____________________________

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