Registration Form

APPLICANT'S Information

Applicant
DOB
Age
Sex
Home Address
City
Zip Code
Phone
Email
Child's Social Security Number*:(last five digits)
School ID Number*:
School Attending
Grade
In case of emergency: Contact Name
Phone
Relationship to applicant:

PARENT / GUARDIAN INFORMATION

  MOTHER / GUARDIAN
Name
Address
Phone-Home
Phone-Work
Occupation
E-mail Address
Registered Voter
  FATHER / GUARDIAN
Name
Address
Phone-Home
Phone-Work
Occupation
E-mail Address
Registered Voter
NUMBER IN HOUSEHOLD
INCOME INFORMATION
INCOME LEVEL
$0,000 - $10,000
$10,001 - $15,000
$15,001 - $20,000
$15,001 - $20,000
$20,001 - $50,000
OVER $50,000
SOURCE OF FAMILY INCOME
FULL TIME EMPLOYMENT
PART TIME EMPLOYMENT
SOCIAL SECURITY
UNEMPLOYMENT
PENSION
PUBLIC ASSISTANCE
OTHER    
ETHNO-RACIAL BACKGROUND
PUERTO RICAN BLACK/AFRICAN AMERICAN
CUBAN CARIBBEAN BLACK
DOMINICAN HAITIAN
NICARAGUAN ANGLO
COLOMBIAN OTHER
HISPANIC HONDURAN    

This is to authorize the release of the information contained on this form to Liberty City Optimist Club of Fl. Inc. I certify that this information is true, and I understand that giving false information may result in my child being disqualified and/or ineligible. I understand that this information is for statistical purposes only and will be kept confidential as stipulated in the Federal Privacy act of 1968. I also understand that I may be contacted by a representative from one of the funding sources below to verify services provided.

Does the participant have physical conditions that will prevent him/her from participating in strenuous athletic activities? If so, explain.

Does participant have a documented disability? (ex; Autism, Emotional/Behavioral disorder, Physical Disability, etc.) If yes, please describe.

CONSENT FOR MEDICAL TREATMENT (MINOR)

As the parent or legal guardian of the participant, I hereby give my consent for emergency medical care prescribed by duly licensed doctor of medicine or doctor of dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent. As parent/guardian of the participant, I understand that the Liberty City Optimist Club insurance is a secondary insurance policy. If I have no family insurance, then and only then will the Liberty City Optimist Club of FL Insurance apply. applicable for injuries incurred during Liberty City Optimist Club activities only.

LIABILITY RELEASE

I/We, the parent(s) / guardian(s) of understand that the Liberty City Optimist Club makes available organized athletic, recreational and educational activities for boys and girls. I/We understand that there are always dangers and risks connected with participation in such activities (particularly contact sports) and, as parent/guardian of the participant named above, I/We hereby give my/our approval of his/her participation only upon the condition of my/our acceptance of responsibility for any and such risks and dangers (including any risks associated with transportation to or from the Club or any Club activities) and I/we do hereby release, indemnify and hold harmless the Liberty City Optimist Club, members, employees, organizers, sponsors and supervisors of all its activities, from any person transporting him/her to or from any Club or activity. I/We hereby give my/our approval for the Liberty City Optimist Club of Florida, Inc. to take and/or use photographs, prints and the likeness of my son and/or daughter in any promotion materials and releases and hold harmless the Liberty City Optimist Club of Florida, Inc. its members, employees, associates, personnel, affiliated organizations, so long as photographs and/or prints are used for the purpose and goals of the Liberty City Optimist Club of Florida, Inc.

PARENT/GUARDIAN EQUIPMENT RESPONSIBILITY

It is further agreed that all equipment and uniforms supplied by Liberty City Optimist Club shall remain the property of said organizations, unless agreed upon by said organization and shall be property cared for by the participant and shall be returned in same condition as issued to participant except for normal wear and tear. Parents/Guardians are responsible and agree to pay replacement value for any damage or loss of equipment.

I Agree All Terms & Conditions