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2. Name
3. Date of Birth
   MM/DD/YYYY
5. Parent's Name*
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Email Address
16. School
17. Grade
18. Weight
20. Select One Youth Sport

    1. Football - $90
    2. Flag Football - $70
    3. Cheerleading - $75
    4. Basketball - $60
22. Shirt Size
    -- Select One --Youth Extra SmallYouth SmallYouth Medium Youth LargeYouth XL LargeAdult SmallAdult MediumAdult LargeAdult XLLargeAdult 2XL

    Select One
23. Pants Size
    -- Select One --Youth XSYouth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XLAdult 2XL

    Select One

25. I hereby acknowledge that health and accident coverage, at the expense of the participant, are required in all organized athletic activities and I also certify that my child is covered by health and accident insurance issued by _____________________ Insurance Company. In addition, I accept full responsibility for medical/hospital expenses and other related expenses not covered by the required insurance for injury received by the above name individual while participating in the athletic program. I understand that by allowing my child to participate, I am assuming all risk, and do hereby hold harmless the City of Moss Point Parks and Recreation Department, their agents and assignees, of responsibility for any such injury, illness, or expenses and waive any and all claims which may arise against them. 

27. Insurance Information*
28. Birth Certificate Information*

30. It is recommended that each child receive a physical examination and approval by a doctor before participation in the sports program. Such medical examination would be at the expense of the participant and the option of which medical doctor is chosen by the participant. Once a player is placed on a team, he/she will remain on the team until he/she becomes ineligible by age. 

    NOTICE………. The Parks and Recreation Department issues a NO REFUND Policy for Youth Sports. 

    My signature below attests that I have read, understand and agree with the terms and conditions and that I give consent for my child to participate in the athletic program designated above.

32. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
34. Electronic Signature
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field