Participant First Name  Participant Last Name  Date of Birth  

Sex:  M   F    Current Grade in school Special Request (Coach or Child) 

Parent First Name  Parent Last Name  City  

Father's Phone Number: Cell ()  Mother's Phone Number: Cell ()  

Father's Email  Mother's Email 

    I am Interested in Volunteering   Name:   Email:

$35 Coed T-Ball - Ages 4, 5, & 6 years old by June 1st, 2021 (No Shirt)

$45 Coed T-Ball - Ages 4, 5, & 6 years old by June 1st, 2021 (Includes Shirts)

$35 Coed Coach/Machine Pitch - Ages 6, 7 & 8, Must have played T-Ball one year (No Shirt)

$45 Coed Coach/Machine Pitch - Ages 6, 7 & 8, Must have played T-Ball one year (Includes Shirts)
 

T-Shirt Size: (check one) Youth Sizes:  S (6/8)  M (10/12)  L (14/16) Adult Sizes:   S   M  L   XL
Each player will receive a one red and one blue shirt of size requested.
 

 Check here if you DO NOT give permission for your minor child/ward(s) picture(s) to be on the City of Hickman Facebook, Website and/or Newsletter.

REGISTRATION DEADLINE: February 27, 2022

Late Fee of $15.00 Will Apply to Registrations Received After February 27, 2022

NO REGISTRATIONS WILL BE ACCEPTED AFTER March 13, 2022

Financial Assistance Program May Be Available

I have read the Parent/Athlete Concussion Information Sheet

***WAIVER AND RELEASE OF LIABILITY***

Please read this form carefully and be aware that in participating you will be waiving and releasing all claims for injuries that you or your minor child/ward might sustain arising out of this participation.

As a participant or parent/guardian of a participant, I recognize and acknowledge that there are certain risks of physical injury and agree to assume the full risk of any injuries, including death, damages or loss which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with this program.

I agree to waive and relinquish all claims I or my minor child/ward may have against the City of Hickman and its officials, officers, agents, servants and employees as a result of participating. I do hereby fully release and discharge the City of Hickman and its officials, officers, agents, servants, employees and volunteers from any and all claims from injuries, including death, damage or loss which I or my minor child/ward may have or which may incur or may accrue to me or my minor child/ward on account of my participation.

I further agree to indemnify and hold harmless and defend the City of Hickman and its officials, officers, agents, servants, employees and volunteers from any and all claims resulting from injuries, including death, damages and losses sustained by me or my minor child/ward and or arising out of connected with, or in any way associated with the activities of my participation.

In accordance with Nebraska Statute 71-9105 (2011), parents and coaches must review the provided items that address the following:

1. The Signs and Symptoms of a Concussion;
2. The Risks Posed by Sustaining a Concussion; and,
3. The Actions an athlete should take in response to sustaining a concussion, including the notification of his or her coaches. (More information is available at www.cdc.gov/concussion/HeadsUp/youth.html)

By signing this form I acknowledge that I have read and fully understand the above warning of Risk and Waiver and Release of All Claims and have received information in accordance with Nebraska Statute 71-9105 regarding concussions.

Parent/Guardian Signature (Required)             Date