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Community Center Child s Name Age Parent s Name Birthdate Sex Address City School Parent s Work Parent’s email Parent Cell Phone Uniform Size: Home Phone Grade Zip YSYMYLASAMALAXL A99L Coach or player request: Sport or Activity Please Note: No guarantee can be made for coach , team or player request Signature of Parent or Guardian Date This form has four sections (1) an assumption of risk and release (2) paragraph of instruction (3) medical authorization and (4) a participant information form.. EMERGENCY AND MEDICAL INFORMATION Person to contact in an emergency: Name Address Telephone (Day) City Zip Telephone (Evening/Weekend) Alternate person to contact in an emergency: Name Address Telephone (Day) City Zip Telephone (Evening/Weekend) Physician: Name Address Telephone City Zip Allergies: Medications: Medical Problems: Insurance Company: Comments: My child may be photographed (stills or video) for the City of Seattle, its Department of Parks and Recreation, the Associated Recreation Council, Advisory Council, or Community Center publications..