3095 Boul. Rome Brossard - Baseball LNDB de Brossard

LNDB Baseball Brossard
L.N.D.B (Loisirs Notre-Dame de Bonsecours)
3095 Boul. Rome Brossard (Québec) J4Y 1R2
⌂ Novice (2008-2009-2010-2011) ⌂ Atome (2006-2007) ⌂ Moustique (2004-2005)
⌂ Pee-Wee (2002-2003) ⌂ Bantam (2000-2001) ⌂ Midget (1997-1998-1999)
⌂ Challenger 8ans et + Servicard (obligatory): ______________________
Information of player
Last name:
First Name:
Birth date (yyyy-mm-dd):
Sex:
Address:
City:
Postal code:
Telephone:
Allergies or other:
Information Parent / Guardian
Father’s name:
Mothers name:
e-mail:
e-mail:
Telephone:
Telephone:
Emergency
contact:
Telephone:
Consent
I ________________________________ authorize my child to participate in the activities of LNDB Baseball Brossard.
I consent to LNDB Baseball Brossard using any photos taken which may include my child’s image to be posted on the
LNDB Baseball web site as well as any local newspaper.
Yes
No
In case of an emergency and the child’s parent/guardian cannot be reached, I authorize LNDB baseball, the coaches,
and/or the officials to take the necessary measures in assuring that the child receives the appropriate medical
attention.
Signature Parent / Guardian _______________________________________ Date________/_______/______
(Signature only)
yyyy
mm
dd
Information for registration: Make a check payable to L.N.D.B Baseball Brossard
Registration Costs:
Novice $80 Challengers $35 (Registration for these categories accepted at all times)
Other categories:
Cost before April 13: Atome & Moustique (140$), Pee-Wee, Bantam et Midget (160$)
Cost after April 13: Atome & Moustique (160$), Pee-Wee, Bantam et Midget (180$)
Registration deadline: April 30, 2015
Do not write in this section, for LNDB administration purposes
Address validated by _________________
Fees paid $____________
paid:
Cash
Check number. ________