Greater St. Louis Area FCA
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Youth Sport Clinic Registration
Please completely fill out all listed fields before submitting.
Student's Full Name
Gender
Boy
Girl
Birthdate
Grade
Mailing Address
City, State and Zip
Home Phone
School student attends:
T-shirt Size
Parent's Email
Please select clinic
select only one
Baseball/Softball
Basketball
Soccer
Football (boys only)
Family Insurance Information
Insurance Company & Policy Number
List any known medical conditions or allergies
Emergency Contact & Phone
I authorize the administration of emergency medical treatment to the subject of this form. I understand that all reasonable safety precautions will be take at all times by the Greater St. Louis Area Fellowship of Christian Athletes (FCA) and the FCA will not be held liable for any accident, injury or disease incurred by the subject of this form. I understand that in the event medical intervention is needed, every attempt will be made to contact the person(s) on this form immediately.
Authorization for Treatment
please select one
I am the legal parent or guardian of the student listed on this form and I DO agree to the terms and conditions listed above.
I am the legal parent or guardian of the student listed on this form and I DO NOT agree to the terms and conditions listed above.
I am NOT the legal parent or guardian of the student listed on this form and a insurance waiver NEEDS TO BE MAILED.
Notes
If you would like to pay by credit card, please PRINT this form to fill in the following information before MAILING it to the Greater St. Louis Area FCA. A $5 processing fee will be added to the registration fee. Please clearly write NAME ON THE CARD, CARD NUMBER, and EXPIRATION DATE
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