Required fields are marked with asterisks (*)

Program Registration Form

4-6 yr. old Co-ed Youth Program

7-9 yr. old Co-ed Youth Program

10-12 yr. old Co-ed Youth Program

Date of Birth

Age as of Sept. 1

Which program are you registering for

Co-ed Youth Soccer

Co-ed Youth Basketball

Co-ed Youth Flag Football

Please Check the age group appropriate based on the league age (Sept. 1)

4-6 yr. Co-ed Youth

7-9 yr. Co-ed Youth

10-12 yr. Co-ed Youth

Date

First Name (Participant)

Last Name (Participant)

Sex

male

female

Coach? If yes, fill out a coach's background check located on our webpage at www.jaspercountysc.gov.

Yes

Address

City

State

ZIPCode

Participants Name

Grade Level

Best Person to Contact

Best Contact Number

Emergency Contact Person

Emergency Contact Phone Number

List any major medical problems and/or medications needed.

By checking yes below I certify that this constitutes a Signature Consent as Parent/Guardian

Yes

Image Release

I agree that my minor child/ward while participating in the Jasper County Parks and Recreation Department youth and adult program, may be photographed or videotaped and that such image may be published in an outlet used to promote or publicize the youth basketball program. (i.e.- local newspaper, Facebook, County website)

Liability & Release Statement

I, the undersigned parent/guardian of the below-listed child, do hereby give my permission for his / her participation in the Jasper County Parks and Recreation Department youth and adult program. I am aware of the nature and extent of the program and do hereby unconditionally release and agree to hold harmless Jasper County Parks and Recreation, its volunteers, and employees from all claims of any kind or nature which may arise in connection with this program. I also give the coaches, staff of the Jasper County Parks and Recreation Department, volunteers, and persons acting on behalf of the Jasper County Parks and Recreation Department permission to seek medical attention for my child in my absence.

COMPLETE REGISTRATION ONLINE WWW.JASPERCOUNTYSC.GOV
BIRTH CERTIFICATE (COPY)
PAY REGISTRATION FEE

*CASH EXACT AMOUNT ONLY. NO CHANGE WILL BE GIVEN.

MAKE MONEY ORDERS PAYABLE TO:

JASPER COUNTY PARKS AND RECREATION

1458 RED DAM RD. HARDEEVILLE, SC 29927

**PAYMENT CAN BE MAILED IN OR DROPPED OFF AT SERGEANT JASPER PARK

1458 RED DAM RD. HARDEEVILLE, SC 29927

DEADLINE: TBD

Date Signed