NEW BIRTH MISSIONARY BAPTIST CHURCH ATHLETICS REGISTRATION FORM

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NEW BIRTH MISSIONARY BAPTIST CHURCH ATHLETICS REGISTRATION FORM 6400 Woodrow Drive, Lithonia, GA







Childs Name: Last:________________________ First:_______________________ M.I. _____ Address: Street/Apt:______________________ City:______________ State:____ Zip:_______ Telephone #: __________________ Gender (Circle One) : Male or Female Age: _______ Date of Birth: ________________ School: ___________________________ Grade: _____ Mother/Guardians Name: _______________________________ Work #: ______________ Father/Guardians Name: _______________________________ Work #: ______________ # of Seasons Played: ________ Last Years Team/Coach:__________________________________ Youth Uniform Size: Shirt (Circle One) : Sm Med Lg Pants/Skirt (Circle One): Sm Med Lg Adult Uniform Size: Shirt (Circle One) : Sm Med Lg Pants/Skirt (Circle One): Sm Med Lg Shoe Size:
MEDICAL INFORMATION Please state any physical problems that we should be aware of, such as asthma, diabetes, epilepsy, etc.
and any medications your child is currently taking:
____________________________________________________________________________________

____________________________________________________________________________________ Is your child allergic to any medications? Yes or No (Circle One) If yes, please list all medications: ____________________________________________________________________________________

Emergency Contact: __________________________________ Telephone #: ________________ I give my child_____________________________________, permission to participate in the

aforementioned sport sponsored by the New Birth Missionary Baptist Church Athletic Ministry.
Parent/Guardians Signature: _________________________________ Date: ______________
Check Appropriate Box: Baseball/Teeball Football Basketball Soccer Bowling Softball Cheerleading Track Bishop Eddie L. Long Senior Pastor Minister Andrew Momon Senior Athletic Director NEW BIRTH MISSIONARY BAPTIST CHURCH ATHLETICS REGISTRATION FORM 6400 Woodrow Drive, Lithonia, GA RELEASE FOR MEDICAL TREATMENT The following is a release for medical treatment for your child. This form gives the New Birth Athletic
Ministry permission to seek medical treatment for your child if he/she is injured and you cannot be
contacted. However, the staff, or designated person(s), the doctors office, and the hospital staff (if
necessary) will make every conceivable attempt to contact you.

I,______________________________________ authorize the New Birth Athletic Ministry staff to seek Print Parents/Guardians Name medical treatment for my child,______________________________ in the event that I cannot be Print Childs Name reached, or the situation requires immediate attention.

Parent/Guardians Signature:______________________________________ Date:______________ Home #: ____________________ Work #: __________________ Cell/Pager #: _______________ Doctors Name:________________________________________________ Office #: _______________ Primary Insurance Co:___________________________________/ Policy No:_____________________
REGISTRATION AGREEMENT ** Registration Fees: All fees will be paid before my child begins practice and receives his/her uniform and/or equipment. ** Refunds: There will be no refunds given. ** Returned Checks: Returned checks will be assessed a $25.00 administration fee.
** Mandatory Coca Cola Fundraiser : 5 case are required to be sold
I do hereby understand the terms of enrollment for my child and assume all risk and hazards/incidents to such
participation, including transportation to/from said activities. I waive, release, absolve, indemnify, and agree to
hold harmless New Birth Missionary Baptist Church and affiliated associations, leagues, the organizers, supervisors, sponsors, officers, directors, coaches, participants, and persons transporting, participants to/from such
activities from any claim rising out of injury.

Parent/Guardians Signature:_____________________________________ Date:______________________ FOR LEAGUE USE ONLY:
Receive 10% Discount for Samson Health & Fitness Center Membership (Circle One) : Yes or No
Amount Paid: $_____________________

Method of Payment (Circle One): Cash Visa Mastercard American Express Check _________ (Check No.)
Copy of Birth Certificate on File (Circle One) : Yes or No Picture On File (Circle One) : Yes or No Bishop Eddie L. Long Senior Pastor Minister Andrew Momon Senior Athletic Director NEW BIRTH MISSIONARY BAPTIST CHURCH ATHLETICS REGISTRATION FORM 6400 Woodrow Drive, Lithonia, GA







Childs Name: Last:________________________ First:_______________________ M.I. _____ Address: Street/Apt:______________________ City:______________ State:____ Zip:_______ Telephone #: __________________ Gender (Circle One) : Male or Female Age: _______ Date of Birth: ______________ School and
current grade: ______________________ I affirm the above information is true and correct. If necessary, I give permission for a
representative of the Athletic Ministry to obtain supporting documentation needed to
confirm the age of my child.
Mother/Guardians Name: _______________________________ Work #: ______________ Father/Guardians Name: _______________________________ Work #: ______________
Association Name: New Birth Age Group: ______ Team: _____________________________
Football Use Only: Heavy Skilled















As a representative of, ___________________________________________________________, we the
undersigned do affirm that the above information is true and correct and that the birth certificate attached to
this affidavit is accurate and reflects correct information for the above listed/pictured child. We also affirm
that the child pictured above plays only on the above team and not on a school or any other organized team.

League Rep Commissioner/president
Check Appropriate Box: Baseball/Teeball Football Basketball Soccer Bowling Softball Cheerleading Track Bishop Eddie L. Long Senior Pastor Minister Andrew Momon Senior Athletic Director




Affix Photo Here NEW BIRTH MISSIONARY BAPTIST CHURCH ATHLETICS REGISTRATION FORM 6400 Woodrow Drive, Lithonia, GA Athletic Ministry Covenant for Participants and Parents 1) I will commit to pray for my role as a parent, participant, my team, the coach (es) and the
ministry as a whole that all woulsd please God and glorify his name in private and in public.
2) I will make my first priority not winning, but rather making sure I as part of the church
body and ambassadors for Christ, do nothing to bring shame or to hinder the cause of Christ
in private or public.
3) I will do my best to make the sports experience fun for my teammates, putting aside any
personal desire to win.
4) I will encourage my child (ren) and teammates in all aspects of the game, showing by
example the proper attitudes in sports in private and in public (set an example for the
believers in speech in life, in love, in faith and in purity. I Timothy 4:12)
5) I will support and encourage my coaches and treat him or her with respect, in private and in
public.
6) My child (ren) and I will entrust the coach (es) to perform the ministry of coaching and
interfere at practices or games by not talking back.
7) My child (ren) and I will display a wholesome attitude towards my peers, teammates, and
competitors through displaying fairness, selflessness and respect in private and in public.
8) My child (ren) and I will display nothing short of the highest respect for
umpires/officials/referees, showing sportsmanship in any given situation.
9) My child (ren) and I will remind my parents that I am to be prompt and punctual for
practices and games.
10) I will be present to support my child (ren) at practices and games whenever possible. If I am
not present at practices and games, I will be on time to pick up my child (ren) or make arrangements with someone elses to do so. [I understand that it is not the coaches
responsibility and if I am not on time (15-minutes grace period), I will have to pick my child
(ren) up from the coachs home. If I am not at the coachs home within an hour after practices
or games, my child (ren) will be released to the Department of Children and Family Services]. By signing this covenant, My child (ren) and I understand that, under Gods grace, I will uphold
these principles to the best of my abilities.


/ Parent Signature Print Name Date
/ Child Signature Print Name Date
/ Greg Taylor General Manager. Signature Print Name Date / Keyna Williams FLC Athletic Associate Print Name Date
Bishop Eddie L. Long Senior Pastor Minister Andrew Momon Senior Athletic Director

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