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CITY OF LOS ANGELES-DEPARTMENT OF RECREATION AND PARKS
WINNETKA RECREATION CENTER
8401 Winnetka Ave., Winnetka CA 91306; (818) 756-7876
SPORTS REGISTRATION FORM
SPORT:
DIVISION:
REGISTRATION #
(for office use only)
P
L
A
Y
E
R
Last Name ________________________________ First Name _____________________________ Male or Female
Birth date _____/_____/_____ Age ______ Grade ______ Height ________ Weight ______ School ______________________
Are you a returning player? Yes No If yes, what Team? ________________ Division? _______________
Do you have a sibling playing in the same division? Yes No
If Yes, Name ______________________________________________________ Age ________
Same team privileges will apply only to siblings
G
E
N
E
R
A
L
Address _____________________________________ City ___________________________, CA Zip Code _________________
Home Phone Number ___________________________ Best time to reach you at home? _______________________________
Parent/Guardian Name ________________________ Work Phone ___________________ Cell Phone___________________
Parent/Guardian Name_________________________ Work Phone ___________________ Cell Phone___________________
EMAIL ADDRESS: _____________________________________________________________________________________
Emergency Contact Person (Another person not mentioned above and over 18 years-old) Name___________________________________
Telephone Number ________________________________ Relationship to participant ________________________________
Please check if you are interested in helping with one of the following: Coach Assistant Coach
Uniform Size: Youth Sizes - Small Medium Large X-Large
(Check One) Adult Sizes - Small Medium Large X-Large XX-Large
PARENT CONSENT FORM
I, the undersigned, give permission for my child, _____________________________, a minor, to participate in the WINNETKA RECREATION CENTER Sports program. I
understand the nature of sports activities and the minor’s experience and capabilities and believe the minor to be qualified, in good health, and in proper physical
condition to participate in such activity. I agree to relieve the City of Los Angeles Department of Recreation and Parks, its officer agents and employees from any
liability in connection with any injury to my child in connection with this league. I understand that the Recreation Facility CARRIES NO INSURANCE.
I, also, do hereby authorize the staff of WINNETKA RECREATION CENTER as agents for the undersigned to consent to X-Ray examination, anesthetic, medical or
surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or specialized supervision of any physician
licensed under the provisions of the Medical Practice Act on the staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said
physician or a said hospital. It is understood that this authorization is given in advance of any such diagnosis, treatment or hospital care that the aforementioned
physician in the exercise of his best judgment may deem advisable. This authorization shall remain effective for the duration of the program, unless revoked sooner in
writing and delivered to the said agent.
Parent/Guardian Signature ______________________________________________ Date__________________________
Photography/Video Release: I hereby give permission to the City of Los Angeles Department of Recreation and Parks to photograph and/or videotape my child.
The sole purpose of these photos and/or videos is for publication, advertisement, and exhibition of services by the City of Los Angeles, Department of Recreation and
Parks.
Parent/Guardian Signature ______________________________________________ Date__________________________
Refund Policy: A non-refundable 15% administration fee will be assessed by the Recreation Center to any patron granted a refund, change or transfer of sports
league registration. Full refunds will only be issued when the league is cancelled by the Recreation Center.
Parent/Guardian Signature ______________________________________________ Date__________________________
(for office use only)
RECEIPT NUMBER#__________
(for office use only)
AMOUNT $__________
(for office use only)
RECEIVED BY (Initial)__________
(for office use only)
AGE VERIFIED (Initial)__________