Please Copy and Paste into a Microsoft Word Document. If you cannot then email at Thomas.Conroy@jefferson.edu for a copy. Put CYO in the subject.

Holy Child CYO

Sports Registration and Contact Information

___________________________    __________       ____     __________ _______

Student’s Name                                                  D.O.B.                        Grade            Sport:            Shirt Size:

___________________________    __________        __________    _________________

Street Address                                                      Zip Code                      Age                         Home Phone #

___________________________    __________        __________    _________________

Grade School                                                      Parish                            Religion                  Player Cell #

_______________________________    ___________________________

Mother’s Name                                                             Father’s Name

______________________________    ____________________________

Mother’s Cell                                                                Father’s Cell

Health Information:                                 Parents email address__________________

______________________________     ____________________________

Insurance Co. Name                                 Policy #

______________________________      ____________________________

Child’s Physician                                      Telephone #

Is your child taking any medication, if so, please list: _____________________________

________________________________________________________________________

List any allergies:_____________________ Inhalers_____________________________

I HEREBY GIVE PERMISSION TO HAVE MY CHILD TAKEN TO THE NEAREST HOSPITAL AND TREATED IN CASE OF AN EMERGENCY.

PARENT SIGNATURE________________________________ DATE:______________

Waiver:  I hereby give permission for my child___________________ to participate on the Holy Child’s team and I will not hold its coaches or representatives liable for any injury that may occur during practice or games.

____________________________                                                    _________________

(Parents Signature)                                                                              (Date)

Participation on Holy Child Sports is a privilege.  Team members and parents are expected to abide by the codes of conduct and to represent the school/parish in a proper manner.  We expect the children to behave reasonably and cooperatively in the school and in their parish communities as well as in practices and games.  Non-Christian behavior and /or academic failure will be grounds for exclusion from participating in any CYO activities (sports, dances etc).