Edgefield County Recreation Department 2022-2023 Registration Form "*" indicates required fields 1Players Information2Parental Information3Consent4Pay & Submit Player InformationName:* First Last Date of Birth* Month Day Year Sex* Male Female School Grade Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Edgefield County Resident* Yes No Contact InformationHome PhoneWork PhoneCell PhoneEmail* PARENTAL AUTHORIZATION*I give my permission for my child to participate in the Edgefield County Recreation Basketball Program. I accept full responsibility for any injury which may occur, and in no way whatsoever, hold Edgefield County Recreation Department or any employee or representative of Edgefield County responsible. All refunds will be subject to a $25.00 administration fee charge! No refunds will be provided after the season begins! I agree.NATIONAL YOUTH SPORTS COACHES ASSOCIATION EMERGENCY Medical and Surgical Treatment Form*The patient and other whose signatures are attached below do hereby consent to any and all medical and surgical treatments including anesthesia and operations which may be deemed advisable by physicians and surgeons. The intention hereof being to grant authority to administer and to perform all and singularly any examinations, treatments, anesthetics, operations and diagnostic procedures which may now or during the course of the patient's care be deemed advisable or necessary. We also agree that the patient when admitted is to remain in the hospital until his or her physician recommends the patient's discharge in witness of our consent and agreement to the matters stated in the three preceding sentences, we have subscribed our signatures below. I UNDERSTANDMinor - Patient* First Last Parent or Guardian* First Last By signing your name electronically on this Registration Form, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this Form. Basketball RegistrationCredit Card*Card Details Cardholder Name
