2021 Spring Clinic Registration Form

Liability

LIABILITY: By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending Girls Place and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Girls Place may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Girls Place employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at Girls Place. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless Girls Place, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Girls Place, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Girls Place program.*

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COVID-19 Precautions & Procedures

HEALTH SCREENING: I consent to daily health screenings of my child(ren). This screening will include temperature checks and questions of health.*

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SUSPENSION OF SERVICES: Girls Place has the right to close or suspension services at any time. All efforts will be made to inform parents/guardians of closure with as much time as possible.*

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SICK POLICY: I understand the Girls Place has the right to refuse service if deemed necessary. Reasons for denial include: temperature of 100.4 degrees, outward signs of sickness (running nose, coughing, etc.). I agree to pick up my child(ren) within an hour of being called.*

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MANDATORY MASK WEARING: I understand that masks will be required at certain times during clinics. More specific information will be available for each clinic.*

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PARENT SUPPLEMENT: I have read and understand the COVID Supplement Guide.*

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Membership

Membership is a one time annual fee that is required to participate in any Girls Place program. Membership fees are $20 for one child and $40 for families with two or more girls participating and are valid from January 1st - December 31st. Membership is nonrefundable and nontransferable. New members will be assessed the appropriate membership fees when they register for the spring volleyball program. Please call (352) 373-4475 if you would like to verify that your membership has been paid for 2020.

2021 Girls Place Membership*

An active 2021 Girls Place Membership is required to participate in all Girls Place programs. If you are unsure of your membership status, please call 352-373-4475.

Player Information

This registration form is for all girls wanting to participate in Spring Sports clinics.

Name*

First Last

Date of Birth*

mm/dd/yyyy

Age*

Height (Feet, Inches)*

Race*

Please list any medical conditions we should be aware of (asthma, allergies, previous injuries, etc.)*

Jersey Size*

Grade Level in AUGUST 2020*

School Attending in AUGUST 2020*

Other school (not listed above)

Please identify.

Address*

Street Address Address Line 2 City State ZIP Code

Main Phone Number*

Parent/Guardian Information

Guardian #1 Name*

First Last

Relationship to Child*

Email Address: MUST be checked regularly*

Place of Employment

Job Title

Office Phone

Cell Phone*

Guardian #2 Name

First Last

Relationship to Child

Email Address: MUST be checked regularly

Place of Employment

Job Title

Office Phone

Cell Phone

Emergency Contact

Emergency Contact's Name*

First Last

Must be someone other than a parent or guardian.

Relationship to Child*

Cell Phone Number*

Work Phone Number

Volunteer with Girls Place Athletics!

Please select any and all positions you are interested in helping with this season.

Volunteer Fundraising
Volunteer Team Sponsor

Demographics

The following is optional and ONLY used to assist us in obtaining funding and various grants. THIS INFORMATION WILL BE HELD CONFIDENTIAL.

Child resides with (check all that apply):

Mother
Father
Stepfather
Stepmother
Grandparent
Aunt/Uncle
Foster Parent
Other

If other, please identify:

Who is the head of household?

Mother
Father
Stepfather
Stepmother
Grandparent
Aunt/Uncle
Foster Parent
Other

If other, please identify:

Annual Family Income*

Please remember that this information is held confidential and is used for reporting purposes and securing grants to better serve you.

Total # of adults (18 and older) in household

Total # of children (0-17 years old) in household

How did you hear about Girls Place?

If other, please identify:

Girls Place Policies and Practices

The following section includes information regarding payments, releases and our programming. Please read this information carefully. You will be held responsible for all of the content. Please contact Charlie at Charlie@girlsplace.net with any questions.

PAYMENT POLICY: Payment for Spring Clinics is due in FULL no later than 6pm on the Friday before your child(ren)'s clinic. Failure to pay by the deadline will result in your daughter being moved to the bottom of the wait list. NO EXCEPTIONS.*

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NON‐SUFFICIENT FUNDS (NSF) POLICY : All NSF checks will be charged a $25 NSF fee. Please pay for all NSF checks with cash or money order, as they will not be re-deposited. After two returned checks within one year, cash payments will be required thereafter for services plus any bank services accrued by Girls Place, Inc.*

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REFUND POLICY: I understand that once my child is placed on a team, I will not be eligible to receive a refund. The Athletic Director and Executive Director shall make the final decision regarding refunds in the event any extenuating circumstances arise.*

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PHOTO RELEASE: I understand that during activities and events at Girls Place my child may be photographed or videotaped by Girls Place staff. I agree that my child or her likeness can be used in Girls Place publications including newsletters, fliers, and brochures in addition to local newspaper and television promotions.

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SOCIAL MEDIA RELEASE: I understand that during activities and events at Girls Place my child may be photographed or videotaped by Girls Place staff. I agree that my child or her likeness can be used in Girls Place's social media outlets like Facebook, Instagram and Twitter.

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CODE OF CONDUCT: I acknowledge that I have reviewed and plan to implement the following Sport Parent Code of Conduct for the important message it holds about the PROPER role of parents in SUPPORTING their child in sports. By initialling below you agree that you (and your guests) will abide by the Code of Conduct. Follow the link to view the Code of Conduct http://www.girlsplace.net/?p=3815*

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CONCUSSION SUPPLEMENT & PROTOCOLS*

Questionnaire: (Please complete in an effort to provide the most positive experience for your children)

What do you expect your child to gain from the Athletic program at Girls Place?

Below, please give us any input that you would like to share about Girls Place or the Athletics program.

For returning families, please share how Girls Place has benefited you and your family. What would your child's life be like without Girls Place?

Signature

I have read and fully understand the contents of this application. I have completed the application to the best of my knowledge and ability. I understand that if any information listed in this application changes, I will notify GIRLS PLACE immediately. The child/children listed above has/have my permission to participate in the activities sponsored by GIRLS PLACE as noted on the program schedules. In the case of an emergency an alternate person will be called if the parent(s) can not be reached by phone. The undersigned, individually and as parent or guardian of the participant, hereby authorize GIRLS PLACE to carry out any measures deemed necessary should an emergency occur, including at the expense of the undersigned, appropriate medical treatment for the participant, and hereby releases the GIRLS PLACE, its employees and agents, from any liability or claims arising out of the participant's engagement in the above described events.

Please type your full name into the box below to serve as your digital signature for this form:*

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