Applicant's Information:

Player's Name:  

          Player's Date of Birth (MM/DD/YYYY):   

Player's Sex:  Male    Female

Street:            

City:     

State:    

          Zip:       

School District:     Township:    

      

          Parent/Guardian Information:

Mom's Name:         

          Mom's Phone Number:  

Mom's Email:             

 

Dad's Name:              

          Dad's Phone Number:  

Dad's Email:             

         

What League are you registering your child for? (Choose One)

          5 Year Old T-Ball (Co-Ed)

6 Year Old T-Ball (Co-Ed)

          7 - 8 Year Old Bantam Baseball (Boys)

9 - 10 Year Old Midget Baseball (Boys)

          11 - 12 Year Old Minor Baseball (Boys)

13-15 Year Old Major Baseball (Boys)

          6-8 Year Old Softball (Girls) 

9-10 Year Old Softball (Girls)

          11-14 Year Old Softball (Girls)

          General Health Information:    

           Is the applicant covered by a health insurance plan (Y/N)   Yes      No

           If YES, please complete the information below:   

           Type: HMO PPO/POSKaiser State Plan  

           Name of Primary Insurance Carrier:     

           Name of Primary Care Physician:          

           Primary Care Physician’s Phone:           

           Are there any known Medical Conditions the player's coach should be aware of?

            Yes      No

           If YES, please explain:   

           Does the applicant have any known allergies of which HAJBA or medical personnel should be aware?   

           Yes      No

           If YES, please list:  

                                                  Agreement

   

   

As parent or legal guardian of this player, I understand that Baseball, Softball and T-ball are dangerous sports, and I approve of my child's participation and will not hold the Howell Area Junior Baseball Association, Incorporated, (HAJBA) or any of its representatives responsible in case of accident or injury. Furthermore, I hereby give permission for any and all medical attention necessary to be administered to my child in the event of any accident, injury, sickness, etc. under the direction of the HAJBA staff. This agreement and release is effective for the time during which my child is participating in the HAJBA program and any tournaments for the current season, including traveling to and from such activities. I also hereby assume the responsibility for payment of any such treatment. I agree that my child will not participate with any Baseball, Soft-ball, or T-ball team or program not recognized, or approved, by HAJBA, for the 2012 season, without prior written consent from the HAJBA Board of Directors. I certify that the information on this registration form that I provided is correct.  

      

    Type YES in this box to acknowledge that you read, understand and agree to the above.

Player Fees are as follows:

TBall: $120 - Major Baseball: $160 - All other Baseball and Softball Divisions: $150

    You must send a check made out to "HAJBA" for the amount of the registration fee. The check should have a date of March 31, 2012 and be sent to this address:

HAJBA

PO Box 241

 Howell, Mi 48844

Please be sure to put your child's name in the Memo field of the check.

Your child is not considered registered for our program until your check is received.

You will receive a confirmation page once this form has been successfully submitted.

An email will be sent to you once your check has been received.

Your check will not be cashed until March 31, 2012.

One online form per child should be submitted.

You can write one check to cover the cost for multiple children.

Check Number     Check Amount     

    Type YES in this box to acknowledge that you understand that your child(ren) will not be considered registered until your check is received.