Email* First Name (Participant)* Last Name (Participant)* Program applying for*
Coed Youth Basketball

Sex*
male
female

Address* City* State* ZIPCode* Date of Birth*



Age as of Sept. 1, 2023*

Grade Level* Name of Parent / Guardian* Phone* Best Person to Contact* Best Contact Number* Emergency Contact Person* Emergency Contact Phone Number* List any major medical problems and/or medications needed.*

Please Check the age group appropriate based on the league age (Sept. 1, 2023)*
7-9 yr. old Coed Youth Basketball
10-12 yr. old Coed Youth Basketball

My child’s shirt size is*
YXS
YS
YM
YL
YXL
AS
AM
AL
AXL
AXXL
AXXXL

Coach?*
Yes
No

If yes, fill out a coach’s background check located on our webpage at www.jaspercountysc.gov.

Coach Shirt Size
AXXL
AXXXL
AS
AM
AL
AXL

Liability & Release Statement

I, the undersigned parent / guardian of the below listed child do hereby give my permission for his / her participation in the Jasper County Parks and Recreation Department 2023 youth soccer program. I am aware of the nature and extent of the program and do hereby unconditionally release and agree to hold harmless Jasper County Parks and Recreation, its volunteers, and employees from all claims of any kind or nature which may arise in connection with this program. I also give the coaches, staff of Jasper County Parks and Recreation Department, volunteers and persons acting on behalf of Jasper County Parks and Recreation Department permission to seek medical attention for my child in my absence.

Participants Name* By checking yes below I certify that this constitutes a Signature Consent as Parent/Guardian*

Yes

Date*

Image Release

I, the undersigned parent / guardian of the below listed child do hereby.

Agree that my minor child / ward while participating in the Jasper County Parks and Recreation Department 2023 youth soccer program may be photographed or videotaped and that such image may be published in an outlet used to promote or publicize the youth volleyball program. (i.e.- local newspaper, Facebook, County website)

Participant Name* Checking yes below I certify that this constitutes a Signature as Parent/Guardian*
Yes

Date Signed*

• COMPLETE REGISTRATION ONLINE WWW.JASPERCOUNTYSC.GOV
• BIRTH CERTIFICATE (COPY)
• PAY REGISTRATION FEE

CASH OR MONEY ORDER $40
LATE REGISTRATION FEE $50
*CASH EXACT AMOUNT ONLY. NO CHANGE WILL BE GIVEN.

MAKE MONEY ORDERS PAYABLE TO:

JASPER COUNTY PARKS AND RECREATION

1458 RED DAM RD. HARDEEVILLE, SC 29927

**PAYMENT CAN BE MAILED IN OR DROPPED OFF AT SERGEANT JASPER PARK

1458 RED DAM RD. HARDEEVILLE, SC 29927

DEADLINE: FRIDAY, NOVEMBER 17, 2023

DEADLINE - LATE REGISTRATION: FRIDAY, DECEMBER 1, 2023

NO REGISTRATIONS/REGISTRATION FEES WILL BE ACCEPTED BEYOND 12/1/23. NO EXCEPTIONS