FAIRFAX POLICE YOUTH CLUB, INC. SPORTS REGISTRATION

P. O. BOX 537, FAIRFAX, VA 22030 CALL FPYC HOTLINE (591-FPYC) FOR INFO

SPORT

HOUSE LEAGUE � TRAVEL TRYOUT � TRAVEL/SELECT LEAGUE �

****VOLUNTEERS***

ARE NECESSARY TO ENABLE THE CLUB TO CONDUCT THIS PROGRAM. PLEASE INDICATE BELOW HOW YOU CAN HELP.

• COACH
• ASSISTANT COACH
• TEAM MANAGER
• REFEREE/UMPIRE/ OFFICIAL
• REGISTRATION ASSISTANT
• GENERAL VOLUNTEER
• OTHER

 LAST NAME

FIRST NAME

AGE

MALE �  

FEMALE �

STREET ADDRESS

CITY

ZIP

PHONE 

(H)

(W)

EMAIL ADDRESS

NEAREST SCHOOL

SUBDIVISION

CHILD’S BIRTH-DATE (M/D/Y)

TOTAL SEASONS IN THIS SPORT

MOST RECENT YEAR

MOST RECENT COACH, CLUB, OR TEAM NAME

MOST RECENT POSITION PLAYED

PRINT NAME OF PARENT/GUARDIAN (FIRST LAST)

 CHILD’S PHYSICAL CONDITION

WEIGHT

HEIGHT

As parents/guardians of the child registered hereon, we hereby approve his/her participation in this activity. I/We hereby assume all risks and hazards of such participation, including transport to and from the activity. I/We do hereby waive, release, absolve and agree to indemnify and hold harmless FPYC, INC., its directors, officers, supervisors, coaches, referees, other participants and persons providing transportation to or from activities for any claim or right arising out of any injury to said child.

We agree to return the uniform and equipment issued to our child in as good a condition as when received except for normal wear and tear.

I/We have read the foregoing release and agreement, understood it, and signed it voluntarily.

Signature of parent or guardian. Persons under 18 may not sign.

__________________________________ Date _____________________________

REGISTRATION $_______

UNIFORM          $_______

DONATION        $_______

TOTAL PAID      $_______

CASH �     CHECK    �

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