ACME Widgets, LLC

Team Name

Team Contact

Phone #

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East Millard Recreation

Recreation Director - Susan Smith

Phone: (435) 555-1998

Payer's Information

First Name:	Last Name:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:
Email:

Cell Phone

Emergency Contact and Phone:

Youth Programs

Baseball:

$40.00

Quantity:

Item Subtotal:

$0.00

Participant's Name	[1]
Shirt Size		[1]
Date of Birth	[1]
Grade	[1]
Are you willing to be a Youth Coach?		[1]
Are you willing to be a Youth Assistant Coach?		[1]
Participant's Name	[2]
Shirt Size		[2]
Date of Birth	[2]
Grade	[2]
Are you willing to be a Youth Coach?		[2]
Are you willing to be a Youth Assistant Coach?		[2]
Participant's Name	[3]
Shirt Size		[3]
Date of Birth	[3]
Grade	[3]
Are you willing to be a Youth Coach?		[3]
Are you willing to be a Youth Assistant Coach?		[3]
Participant's Name	[4]
Shirt Size		[4]
Date of Birth	[4]
Grade	[4]
Are you willing to be a Youth Coach?		[4]
Are you willing to be a Youth Assistant Coach?		[4]

Softball:

$40.00

Quantity:

Item Subtotal:

$0.00

Participant's Name	[1]
Shirt Size		[1]
Date of Birth	[1]
Grade	[1]
Are you willing to be a Youth Coach?		[1]
Are you willing to be an Assistant Coach?		[1]
Participant's Name	[2]
Shirt Size		[2]
Date of Birth	[2]
Grade	[2]
Are you willing to be a Youth Coach?		[2]
Are you willing to be an Assistant Coach?		[2]
Participant's Name	[3]
Shirt Size		[3]
Date of Birth	[3]
Grade	[3]
Are you willing to be a Youth Coach?		[3]
Are you willing to be an Assistant Coach?		[3]
Participant's Name	[4]
Shirt Size		[4]
Date of Birth	[4]
Grade	[4]
Are you willing to be a Youth Coach?		[4]
Are you willing to be an Assistant Coach?		[4]
Participant's Name	[5]
Shirt Size		[5]
Date of Birth	[5]
Grade	[5]
Are you willing to be a Youth Coach?		[5]
Are you willing to be an Assistant Coach?		[5]
Participant's Name	[6]
Shirt Size		[6]
Date of Birth	[6]
Grade	[6]
Are you willing to be a Youth Coach?		[6]
Are you willing to be an Assistant Coach?		[6]
Participant's Name	[7]
Shirt Size		[7]
Date of Birth	[7]
Grade	[7]
Are you willing to be a Youth Coach?		[7]
Are you willing to be an Assistant Coach?		[7]
Participant's Name	[8]
Shirt Size		[8]
Date of Birth	[8]
Grade	[8]
Are you willing to be a Youth Coach?		[8]
Are you willing to be an Assistant Coach?		[8]
Participant's Name	[9]
Shirt Size		[9]
Date of Birth	[9]
Grade	[9]
Are you willing to be a Youth Coach?		[9]
Are you willing to be an Assistant Coach?		[9]
Participant's Name	[10]
Shirt Size		[10]
Date of Birth	[10]
Grade	[10]
Are you willing to be a Youth Coach?		[10]
Are you willing to be an Assistant Coach?		[10]

Soccer:

$50.00

Quantity:

Item Subtotal:

$0.00

Participant's Name	[1]
Date of Birth	[1]
Grade	[1]
Are you willing to be a Youth Coach?		[1]
Are you willing to be an Assistant Coach?		[1]
Participant's Name	[2]
Date of Birth	[2]
Grade	[2]
Are you willing to be a Youth Coach?		[2]
Are you willing to be an Assistant Coach?		[2]
Participant's Name	[3]
Date of Birth	[3]
Grade	[3]
Are you willing to be a Youth Coach?		[3]
Are you willing to be an Assistant Coach?		[3]
Participant's Name	[4]
Date of Birth	[4]
Grade	[4]
Are you willing to be a Youth Coach?		[4]
Are you willing to be an Assistant Coach?		[4]

Volleyball:

$40.00

Quantity:

Item Subtotal:

$0.00

Participant's Name	[1]
Shirt Size		[1]
Date of Birth	[1]
Grade	[1]
Are you willing to be a Youth Coach?		[1]
Are you willing to be an Assistant Coach?		[1]
Participant's Name	[2]
Shirt Size		[2]
Date of Birth	[2]
Grade	[2]
Are you willing to be a Youth Coach?		[2]
Are you willing to be an Assistant Coach?		[2]
Participant's Name	[3]
Shirt Size		[3]
Date of Birth	[3]
Grade	[3]
Are you willing to be a Youth Coach?		[3]
Are you willing to be an Assistant Coach?		[3]
Participant's Name	[4]
Shirt Size		[4]
Date of Birth	[4]
Grade	[4]
Are you willing to be a Youth Coach?		[4]
Are you willing to be an Assistant Coach?		[4]

Flag Football:

$40.00

Quantity:

Item Subtotal:

$0.00

Participant's Name	[1]
Shirt Size		[1]
Date of Birth	[1]
Grade	[1]
Are you willing to be a Youth Coach?		[1]
Are you willing to be an Assistant Coach?		[1]
Participant's Name	[2]
Shirt Size		[2]
Date of Birth	[2]
Grade	[2]
Are you willing to be a Youth Coach?		[2]
Are you willing to be an Assistant Coach?		[2]
Participant's Name	[3]
Shirt Size		[3]
Date of Birth	[3]
Grade	[3]
Are you willing to be a Youth Coach?		[3]
Are you willing to be an Assistant Coach?		[3]
Participant's Name	[4]
Shirt Size		[4]
Date of Birth	[4]
Grade	[4]
Are you willing to be a Youth Coach?		[4]
Are you willing to be an Assistant Coach?		[4]

Jr. Jazz

Jr. Jazz Basketball:

$40.00

Quantity:

Item Subtotal:

$0.00

Participant's Name	[1]
Grade	[1]
Date of Birth	[1]
Are you willing to be a Youth Coach?		[1]
Are you willing to be an Assistant Coach?		[1]
Participant's Name	[2]
Grade	[2]
Date of Birth	[2]
Are you willing to be a Youth Coach?		[2]
Are you willing to be an Assistant Coach?		[2]
Participant's Name	[3]
Grade	[3]
Date of Birth	[3]
Are you willing to be a Youth Coach?		[3]
Are you willing to be an Assistant Coach?		[3]
Participant's Name	[4]
Grade	[4]
Date of Birth	[4]
Are you willing to be a Youth Coach?		[4]
Are you willing to be an Assistant Coach?		[4]

Jr. Jazz Jersey:

$7.00

Quantity:

Item Subtotal:

$0.00

Jersey Size				[1]
Jersey Size				[2]
Jersey Size				[3]
Jersey Size				[4]
Jersey Size				[5]
Jersey Size				[6]
Jersey Size				[7]
Jersey Size				[8]
Jersey Size				[9]
Jersey Size				[10]

Jr. Jazz Shorts:

$7.00

Quantity:

Item Subtotal:

$0.00

Short Size				[1]
Short Size				[2]
Short Size				[3]
Short Size				[4]
Short Size				[5]
Short Size				[6]
Short Size				[7]
Short Size				[8]
Short Size				[9]
Short Size				[10]

Additional Game Tickets:

$12.00

Quantity:

Item Subtotal:

$0.00

Would you like a FREE ticket to a Jazz game or (2) MHS tickets?

Adult Programs

Men's Basketball:

$300.00

Select:

Item Subtotal:

$0.00

Women's 5X5 Volleyball:

$210.00

Select:

Item Subtotal:

$0.00

Women's Soccer:

$450.00

Select:

Item Subtotal:

$0.00

Co-Ed Softball:

$360.00

Select:

Item Subtotal:

$0.00

Co-Ed Volleyball:

$240.00

Select:

Item Subtotal:

$0.00

Registar As An Individual:

$30.00

Quantity:

Item Subtotal:

$0.00

Phone #	[1]
Email Address	[1]
Phone #	[2]
Email Address	[2]
Phone #	[3]
Email Address	[3]
Phone #	[4]
Email Address	[4]
Phone #	[5]
Email Address	[5]
Phone #	[6]
Email Address	[6]
Phone #	[7]
Email Address	[7]
Phone #	[8]
Email Address	[8]
Phone #	[9]
Email Address	[9]
Phone #	[10]
Email Address	[10]

Tri For Freedom Triathlon

If you register between May 14th - June 11th

Individual:

$20.00

Select:

Item Subtotal:

$0.00

Team :

$40.00

Select:

Item Subtotal:

$0.00

Team Contact/Team Member 1
Email
Phone
Shirt Size
Team Member 2
Shirt Size
Team Member 3
Shirt Size

If you register between June 11th - July 2nd

Individual:

$25.00

Select:

Item Subtotal:

$0.00

Team :

$50.00

Select:

Item Subtotal:

$0.00

Team Contact/Team Member 1
Phone #
Email
Shirt Size
Team Member 2
Shirt Size
Team Member 3
Shirt Size

If you register the day of July 3rd

Individual :

$30.00

Select:

Item Subtotal:

$0.00

Team:

$60.00

Select:

Item Subtotal:

$0.00

Team Contact/Team Member 1
Phone #
Shirt Size
Email
Team Member 2
Shirt Size
Team Member 3
Shirt Size

Total:

$0.00

Payment Information:

Processing Fee Rates:
Cards:	3% plus $0.55 ($1.55 min) (1.5% surcharge for foreign cards)
eCheck:	$0.55

Method of Payment:	Credit/Debit Card eCheck
Update Name from Above

Name on Account:
Routing Number:
Account Number:
Institution:

Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:

Change Payment Method

Release of Liability/Consent Form:

The individual registering is physically fit & otherwise able to participate in this program. I understand that the program will be supervised and I further understand that the Millard County Recreation Department and its employees and volunteers will not be held liable for any accidental injury incurred while participating. I authorize emergency treatment to the above named participant for any accident or illness and consent to allow East Millard Recreation and their volunteers to use their discretion in approving necessary medical care. I understand that it is my obligation and responsibility to provide medical insurance coverage for any injury sustained while participating in this program.

Code of Conduct Agreement:

As a parent/guardian or participant I agree to adhere to the East Millard Recreation code of conduct guidelines that include demonstrating sportsmanlike conduct at all times. I agree to treat all volunteers, teammates, refs and recreational staff with respect and understand that vulgar or offensive language and poor sportsmanship directed at anyone involved will not be tolerated. I also understand that the use of drugs and/or alcohol is prohibited on county property or any facility being used for East Millard Recreation events and agree to abide by these regulations. I also agree to treat county property and equipment properly and may be held responsible for any damage or misuse. If at any time I neglect to follow these guidelines I may be asked to leave the premise and participation may be suspended or terminated as deemed necessary by the East Millard Recreation supervisory staff.

Participant

I have read and agree to the statements above.

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