Registration For: INSTRUCTIONAL BASEBALL

Sex (M/F)

State

Does the above participant have medical insurance? Yes NoDoes the above participant have any medical conditions that N.K.Y.A. needs to be aware of? Yes No

If yes above, please explain:

Has the participant played for this coach within the last twelve (12) months? Yes No

Would you be willing to volunteer any time or skills to assist the N.K.Y.A. Organization? Yes No

O Youth X-Small (4-6) O Youth Medium (10-12) O Adult SmallO Youth Small (6-8) O Youth Large (14-16) O Adult Medium

$1 of your Registration fee is applied to Membership Dues.

O Birth Certificate on File (returning to organization) O Birth Certificate checked (new player)

Cash

Player Requested

email address

For Registrar Use Only

* I have read the Northern Kentucky Youth Association Concussion Information Sheet and understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors. I agree that my child must be removed from practice/play if a concussion is suspected.* I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me.* I understand that my child cannot return to practice/play until providing written clearance from an appropriate health care provider to his/her coach.* I understand the possible consequences of my child returning to practice/play too soon.* Information Packet is located under Documents at www.nkya.com.https://bsbproduction.s3.amazonaws.com/portals/6912/docs/2016_nkya_headsupconcussion.pdf

Coach / Player Request

Amount Paid Check # Accepted By: Date

Division

I, the parent/guardian/participant, in consideration of being allowed to participate in any way in the NORTHERN KENTUCKY YOUTH ASSOCIATION (hereby known as N.K.Y.A.) sports/activities program and related events and using the facilities provided by N.K.Y.A. does so at his/her/my own risk. N.K.Y.A., its board of directors, volunteers, agents, shall not be liable for any damages whatsoever arising from any personal injury or property loss sustained by participant and his/her/my family in or about any programs provided by the N.K.Y.A. I acknowledge that I am aware of the risks inherent in participating in the N.K.Y.A. programs/activities and understand that they may require physical exertion; and could potentially lead to injuries that may cause permanent disability and/or death. Participants and parents assume full responsibility for all injuries and damages which may occur in or about any programs and on any premises that N.K.Y.A. uses. He/she/I do or does hereby fully and forever release, discharge, and hold harmless the N.K.Y.A., all associated facilities and its owners, employees and agents from any and all claims, demands, damages, right of action, present or future resulting from or arising out of any person's participation in any programs/activities. Also, waiver all rights to any photos taken for use in any Northern Kentucky Youth Association publication.

Signature

Coach Requested

Current Age

Mailing Address & EmailP.O. Box 6748

Florence, KY 41022info@nkya.com

BASEBALL Registration FormVisit us online at: www.nkya.com

Northern Kentucky Youth Association

Participant Information

Date

Contact Phone Number

Mother's Name Father's Name

Contact Information (Must complete if participant is a minor)

School

Jersey Sizes (please select one)

Waiver / Exclusion Clause (Please read carefully and sign below)

First Name

Zipcode

Last Name

Address

Date of Birth

City