Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Cell Phone *

(###)

###

####

Permission Waiver *

I understand that information may be needed to verify eligibility for this program and to coordinate services with other organizations; therefore, I agree that organizations may share my child’s information. I certify that the information supplied is true and correct and that SMAA staff have my permission to verify the information on this application. I understand that my child’s participation in this program requires a commitment to attend a minimum of 80% of the scheduled practices and games. I understand that my child’s registration information is public record and, as such, may be released under the Freedom of Information Act. I understand that my child's picture and first name may be used for promotional purpose of sponsors and partner organizations.

Yes, I agree

Athlete's Name *

First Name

Last Name

Athlete's Gender *

Male

Female

Athlete's Date of Birth *

MM

DD

YYYY

During which season is your athlete interested in playing? *

Spring

Summer

Fall

Winter

Year-Round

Total Houshold Income *

Less than $35,000

Between $35,000 - $85,000

Between $85,000 - $150,000

More than $150,000

Is your athlete or household enrolled in any of the following programs?

Free or Reduced School Lunch

Temporary Assistance for Needy Families

Aid for Dependent Children

Foster Care

Medicaid