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| GENERAL INFORMATION |
| Activity or event you wish to register for | |
| Participant Name | |
| Gender |
Male
Female
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| Date of Birth | |
| Email | |
| Street Address | |
| City | |
| Zip | |
| Phone | |
| Jersey Size |
S
M
L
XL
XXL
YS
YM
YL
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| Jersey No. Request | |
| PARENT INFORMATION (if participant is under 18) |
| Full Name | |
| Email | |
| Street Address | |
| City | |
| Zip | |
| Phone 1 | |
| Phone 2 | |
| Would you like to serve as a coach? |
Yes
No
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| Coach / Teammate Request | |
| IN CASE OF EMERGENCY CONTACT INFORMATION |
| ICE Name | |
| Relationship | |
| Phone 1 | |
| Phone 2 | |
| HEALTH INFORMATION |
| If participant has any disabilities, handicaps, current injuries, or limitations, allergies, hemophilia, heart condition, history of respiratory illness, special dietary needs, etc; please list here. | |
| LIABILITY RELEASE AND DISCLAIMER |
| I (parent or guardian on behalf of my minor child or student participant) acknowledge that participation in athletic events necessarily involves risk of physical injury. I further acknowledge that the programs of Gateway Baptist Church are primarily administered by parents, who volunteer their time, rather than paid professionals. In consideration for accepting the registration of the above named individual and permitting the voluntary participation of said individual in its programs, I hereby release, forever discharge, and hold harmless the church, its employees, volunteers, and other representatives from any liability, claims, or demands arising out of or relating to any physical injury, sickness, or death as well s property damage and expenses, of any nature whatsoever that may result to said individual while participating in the church’s sponsored events. |
| Accept |
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| I hereby grant or deny permission to Gateway Baptist Church, Atoka, TN to use the image of myself or my child as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images and/or video taken of myself or my child for use in materials that include, but may not be limited to printed materials such as brochures and newsletters, videos, and digital images such as those on the Gateway Baptist Church Web site. |
| MEDIA RELEASE |
| Deny permission to use my (or my child’s) image |
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| Grant permission to use my (or my child’s) image |
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| PLEASE REVIEW YOUR INFORMATION TO MAKE SURE EVERYTHING IS CORRECT. WHEN YOU HAVE FINISHED, PLEASE HIT THE SUBMIT BUTTON |
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