Home of the Crusader Youth Activities Association Sports Programs 2019-20 Basketball Registration CYAA and Diocese of Harrisburg Office for Youth and Young Adult Ministry SPORTS REGISTRATION FORM PARENTAL PERMISSION AND CONSENT TO TREATParticipant's Name* First Middle Last Participant's Status*NewReturningBirth Date* MM DD YYYY Age*Grade*Gender*MaleFemaleUniform Size*Youth SmallYouth MediumYouth LargeYouth X-LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAddress* Street Address City Zip Parish/CCDSchool Attending*Parent/Guardian Name* First Last Home Phone*Work Phone*Cell PhoneEmail* Secondary Email Interested in volunteering with CYAA for Basketball or CheerleadingYesNoI,Parent/Guardian First Last grant permission forParticipant's Name First Last to participate inSport/Event*BasketballCheeringduring the 2019/2020 season.I, the parent/guardian of the registrant, agree that the registrant and I will abide by the rules of the C.Y.A.A. I understand that the program will have competent adult supervision and reasonable and appropriate measures will be made to minimize the risk of injury and/or accident. I understand and have been informed that taking part in this youth trip or event involves the risk of injury. I hereby grant consent for the coach, chaperone, and/or adult volunteer under whose auspices the program is conducted, to secure all necessary emergency medical care and/or treatment that may be necessary for my child during the entire youth trip/event including any necessary transportation, if provided by the coach, chaperone, or adult volunteer. I release and hold harmless any said coach, chaperone, or adult volunteer, from any liability, who in good faith is placed in a position requiring decisions to be made for emergency care or medical treatment of the above-named young person. In case of accident, injury or loss, neither my family nor I will hold the diocese, the parish, the place where the event is conducted, the group sponsoring the event, C.Y.A.A., nor any person or affiliate organization associated with the event responsible or liable. In the event of an emergency, if you are unable to reach me at the above number, contact:Emergency Contact Name* First Last Relationship to Participant*Emergency Contact Phone*Family Physician*Family Physician Phone*Allergic reactions (medications, food, insects)*Medication(s) currently being taken*My child has special medical / mental conditions*YesNoPlease describe your child's special medical / mental conditionsInsurance Company*Policy Number*SignatureQuestions? 717-824-6641 or firstname.lastname@example.orgRegistration Cost Price: $50.00 Registration Cost Price: $100.00 Registration Total $0.00 NameThis field is for validation purposes and should be left unchanged.