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Step One

YOUTH CO-ED KICKBALL LEAGUE REGISTRATION
Spring Registration 2023: January 1 - March 3
Child's Name*
Male (or) Female*
Birthday*
Grade*
Age*
Address*
Address
City*
State*
Zip*
Phone Number*
Shirt Size*
Has the participant played in Jacksonville before?*
Allergies
Medical Conditions
Emergency Contact*
Cell Phone*
Relationship:
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Step Two

Dad's Name*
Phone Number*
Email
Dad's Mailing Address*
City/State/Zip*
Mom's Name*
Phone Number*
Email
Mom's Mailing Address*
City/State/Zip*
Would you like to coach?
Would you like to referee?
Name of Coach (and/or) team preferred?
List any sibling/friend your child wants to play with?
List any other special requests, questions, or concerns.
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Step Three

Waiver
LIABILITY/PHOTO RELEASE AGREEMENT & CONSENT FOR MEDICAL TREATMENT OF A MINOR: I hereby release and forever discharge the Jacksonville Parks & Recreation Department, the City of Jacksonville, and their employees from any and all manner of claims, causes of action, or liability, which may exist or may exist at any time in the future, arising out of or pertaining to any injury, loss, damage, or harm of any kind which has, will or may result or occur while participating in this program. As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or wellbeing of my dependent. I hereby consent to the use, reproduction, editing, and/or broadcast by the City of Jacksonville, Arkansas of any and all photographs, video recordings, and audio recordings of me and/or my family, taken by or on behalf of the Jacksonville Parks & Recreation department, without any compensation to me. All negatives and positives prints video-recorded images and audio recordings shall constitute the property of the City of Jacksonville solely & completely.
Waiver Agreement*
Payment can be paid online (see link below) OR bring a copy of this form to the Community Center to pay in person.
Youth Kickball Registration Payment
Online Registration Link
If you have any questions contact Quincy the Youth Sports Coordinator, Quincy @ 501-690-1722.

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2023 Spring Youth Co-ed Kickball Registration

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