LeBoeuf Little League Web Site Registration Form
Registration Days (all 3 locations) - Bring this completed form to signups
Mill Village Boro Building / Summit Township Building / Stancliff Hose Co. (Waterford)
February 20 (10am-Noon)
February 23 (6pm-8pm)
February 26 (6pm-9pm)
Late signup fee: $45/player - Late signups close March 12th - Fundraiser must be paid at late signup. .
Participants Name:___________________________ Phone: ___________
Parent(s)/Guardian(s): ____________________________ Other Phone: __________
Address: ________________________State: ______ Zip: ______ E-Mail ______________________
Date of Birth: Month___ Day___ Year___ Check one: __Male __Female
Family Physician: ___________________________________________
List Allergies: ______________________________________________
Significant Past Illness or Injury:_______________________________
Emergency Contact:____________________________Phone:_________
In case of Emergency, if family physician can't be reached, I hereby authorize the above
named participant to be treated by another qualified physician who is available.
As the parent or guardian of the above named player, I hereby give my consent to his/her participation in any and all team activities during the current season. I assume all risks and hazards incident to such participation, including transportation to and from activities and I do hereby waive, release, absolve, indemnify and agree to hold harmless LeBoeuf Little League, the organization, sponsors, supervisors, participants and persons transporting my child to or from activities, for any claim arising out of an injury to my child, including any fundraising activity by the LeBoeuf Little League. I understand any insurance carried by LeBoeuf Little League is secondary coverage. I agree to return upon request the uniform and any other equipment issued to my child in as good condition as when received, except for normal ware and tear. If not, I agree to replace it. I will furnish a certified birth certificate of the above named candidate upon request to the LeBoeuf Little League officials. As an adult participant, I agree to the above.
Parent/Guardian Signature_______________________________ Date:_________
Uniform Size: Youth Adult
Small(6-8) Med.(10-12) Large(14-16) XL Small(34-36) Med.(38-40) Large(42-44) XL(46-48)
Shirt: ___ ___ ___ ___ ___ ___ ___ ___
-- OFFICIAL USE ONLY --
Check one: ____T-Ball ____Baseball ____Softball ____Challenger League Age: _______
(if applicable) ___North ___South
LLL Rep: _________________ Sign up location: M/W/S Birth Cert. Presented (Yes)____
Fundraisers Distributed: Paid at Signups:
Candy: ___ x $40 = ___ $_____ Signup Fee ($35 Single - $65 Family)
Buyout: ___ x $20 = ___ $_____ Fundraiser Paid Paid
Fundraiser Due: $_____
$_____ Total Paid (this form) _____ (check#, "CASH" or sibling name)
Associated Sponsor (if any): ________________________________