Platinum Play Registration - Women's Kickball
Did you play during this year's 2017 Spring and/or Summer season?
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Yes
No
Cost of Participation - Returning Player
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$75.00
Cost of Participation - New Players
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$110.00
First & Last Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Phone Number
E-mail
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E-mail
Medical Information
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List any know allergies or medical conditions that needs specific attention during this program.
Emergency Contact Name
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First Name
Last Name
Emergency Contact Phone Number
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Phone Number
Choose your team
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Free Agent
Babes With Attitude
Cuties N' Cleats
GA Power
Kick Astros
Kickball Queens
Pretty Girls Kick
ANY CHANGES? Use the box below to input changes to your address, phone number, medical information, emergency contact name, emergency contact number, kickball name, jersey number, jersey size or "at kick" song
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Kickball Name
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The name you want on the back of your jersey
Jersey Number
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Include at least 2 or 3 #'s just incase it's taken. Example: 02, 14, 27
"At Kick" song
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An uptempo song to get you hype
Jersey Size
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X-Small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Jerseys run small
Photo Permission
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I hearby grant Platinum Play Sports to use my likeness in photos and/or videos for promotional and marketing purposes. I waive all rights to an opinion, royalties and/or compensation related to the use of my likeness.
Release and Waiver Agreement
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In consideration of being allowed to participate in any way in Platinum Play athletic sports programs, related events and activities, the undersigned acknowledges, appreciates, and agrees that: 1) I KNOWINGLY AND FREELY ASSUME ALL RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, 2) I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Platinum Play Sports, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
Signature
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Type your full name as signature
Today's Date
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Month
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Day
Year
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Registration Total
Registration Payment Amount
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