McIntosh County Department
of Leisure Services
Check One: Male_______________Female_______________
Shirt Size: Youth Small 6-8: Youth Medium 10-12: Youth Large 14-16:
Adult Small: Adult Medium: Adult Large: Adult X-Large: Adult XX-Large:
Check One: I Do________Do Not_______ wish for my child to have the offered Insurance Policy. At the cost
Child's Physical Condition___________________________________________
List any Physical or Mental condition or diseases(Epilepsy, Heart Murmur, Rheumatic Fever, Etc.) Which your
child may have or any other special Medical Information:________________________________________________________.
Parent or Guardian Statement
I,we the parents/guardian of the above-named boy or girl, hereby give my/our approval for his/her participation
in activities during the current season. I/we assume all ricks and hazards incidental to the conduct of the activities
and transportation to and from activities. I/we do further hereby release, absolve, indemnify and hold harmless the
McIntosh County Department of Leisure Services, the organizers of the activity, sponsors the supervisiors any or all of them.
In case of injury to my/our son or daughter, I/we hereby waive all claims against the orgnaizers, the sponsorss, or any of
the supervisors appointed by them. I/we likewise release from responsibility any person transporting my son or daughter
to or from the activity.
I/we, the parents of the above-named boy or girl, hereby
give my/our permission to the person in charge of the activity to take our son or daughter to the doctor or hospital in case
of emergency or injury.
Last Day of Registration will be at LEISURE SERVICE GYM FROM:
NO TEAM REQUEST ACCEPTED FEE$20.00-INSURANCE$6.00