Player’s Name:____________________________________________

Date of Birth: _________________

Address:__________________________________________________

Home Phone: ___________Work Phone: ___________ Sex: M ___ F ____School:_______________________________________________

Parent/Guardian Name(s):____________________________________

Parent Email Address:________________________________________

Primary Disability:___________________________________________

Circle the following items that pertain to your child:
Visually Impaired 
Hearing-Impaired 
Uses Sign Language 
Uses a Wheelchair
Uses a Walker
Other accommodations and/or needs. Please list:__________________

T-shirt Size: YM  YL  AS  AM  AL  AXL  AXXL

Will you need a buddy? YES ______ NO _______

IF NO: (Please circle one) Will you bring your own buddy / or a buddy is not necessary

Buddy’s Name: _______________________________________________
(all buddy’s must be 4th grade or higher)

Buddy’s Phone Number: _________________________

Are you interested in volunteering:

Manager _____ Assist Coach _____ Team Parent _____ Umpire ____

Buddy ____ Other_______

I/We, the parent(s)/guardian(s) of the above named candidate for a position on a Little League team, hereby give my/our approval to participate in any and all Little League activities, including transportation to and from the activities.

I/We know that participation in baseball or softball may result in serious injuries and protective equipment does not prevent all injuries to players, and do hereby waive, release, absolve, indemnify and agree to hold harmless the local Little League, Little League Baseball, Incorporated, the organizers, sponsors, supervisors, participants and persons transporting my/our child to and from activities for any claim arising out of any injury to my/our child whether the result of negligence or for any other cause.

Little League Baseball does not limit participation in its activities on the basis of disability, race, color, creed, national origin, gender, sexual preference or religious preference.

Parent(s)/Guardian(s) signatures: _______________________ Date: ____________

If you need more information or have any questions, please contact Assistant District Administrator Lisa Shealy at (850) 668-9428 or email sports4specialkids@comcast.net