Registration Form - Line Drive Athletics

Player Information
Player Name*
First Middle Last
Gender*
- Male
- Female
School Name
Grade*
Birth Date*
Date Format: MM slash DD slash YYYY
Age*
Parent/Guardian Contact Information
Parent/Guardian #1*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Daytime Phone
Cell Phone*
Email*
Enter Email Confirm Email
Parent/Guardian #2
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Daytime Phone
Cell Phone
Email
Enter Email Confirm Email
Alternate Pickup/Release Information
Name
First Last
Home Phone
Daytime Phone
Cell Phone
Email
Enter Email Confirm Email
Relation to child
Medical Release Information
Insurance Information
Name of Health Insurance Provider*
Policy Number*
Primary Physician*
Address*
Street Address Address Line 2 City State ZIP Code
Physician Phone*
Hospital Preference*
Does your child have any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).*
- Yes
- No
Medical Problem*
Required Treatment*
Should paramedic by called?*
- Yes
- No
Medical Problem
Required Treatment
Should paramedic by called?
- Yes
- No
Consent Acknowlegements
Medical Emergency Consent*
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.
Medical Expenses Consent*
I understand that the Line Drive Athletics Softball Camp will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.
Photo Release Consent*
I hereby give permission for my child to be photographed during the Line Drive Athletics Softball Camp. I understand the photos may be used for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed.
Terms of Agreement*
Line Drive Athletics Softball Camp and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).
Date
Date Format: MM slash DD slash YYYY
Signature*
Printed Name of Parent/Guardian*
First Last
Payment
How would you like to pay?*
- Mail Check
- Pay Online
Please select the training you would like to register for:*
- Summer Camp
- Clinic
- Private Lessons
YOUTH - T-Shirt size
- Small
- Medium
- Large
- Extra Large
ADULT - T-Shirt size
- Small
- Medium
- Large
- Extra Large
Which Camp will this child be attending?*
- $199.99 - Beginner Camp
- $249.99 - Advanced Summer Camp
BEGINNER (recommended for ages 5-9 or players of all ages with limited experience)
ADVANCED (recommended for ages 10-14 or players of all ages with 3+ years experience)
Private Lessons*
- $50.00 - 1 Player
- $65.00 - 2 Players
- $80.00 - 3 Players
45 minutes
Which Clinic would you like to pay for?*
Which day would you like for the Winter Clinic training?*
- January 10, 2021
- January 17, 2021
Please mail your payment to:
Line Drive Athletics
2338 Big Pine Dr
Matthews, NC 28105

Please write camper's name on check.
Credit Card*
American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Coupon
Total
$0.00

Please complete our online registration form below.

You may also make a payment at the end of the form, to reserve your child’s spot.

Player Information

Parent/Guardian Contact Information

Alternate Pickup/Release Information

Medical Release Information

Consent Acknowlegements

Payment