Southland Baseball Showcase  
Registration Form   FAX: 714-844-4726
June 11, 2005 @ Point Loma University

High School Name: _________________________________ Primary Position: ________________

Players Name: _____________________________________ Date of Birth ___/____/____

Street Address:
____________________________ City ___________ State ______

Zip Code __________ E-Mail Address: ____________________________________________

What size of bat do you use? __________  Shirt Size  _____________________________

Height: _________ Weight: __________ Bats: _________Throws: _______________

GPA: ______________ ACT/SAT Score: ___________________ SAT2 _____________  Graduation Year: _________

Travel/Scout Team _______________________________________________________

Parentís Full Name: Mother ______________________________ Father ___________________________

Phone Number: ______ - _______ - ______________ Playerís Cell Phone Number: ______ - _______ - ______________

I approve my child's participation at the Southland Baseball showcase event. I expressly represent to Southland Baseball that my child is in good health and physically capable of participating in any and all activities sponsored and associated with Southland Baseball. I authorize Southland Baseball or its representative to request and obtain emergency medial care/treatment for myself or my child as the circumstance may require and in connection with this authorization I hereby waive and release the right to authorize to authorize and give consent for the delivery of medical care/treatment, of whatsoever kind and nature, to my child. I understand that Southland Baseball, its staff members, associates, workers, and anyone associated with Southland Baseball is harmless and release them from any liability from injury as a result of my child's participation in any activity sponsored by Southland Baseball. This release of liability is based on the recognition that sport activities of any kind or nature clearly involves the risk of injury or hazards to the participants and spectators and I acknowledge that my child and I assume such risk when we participate in activities sponsored by Southland Baseball. It is understood that once a player signs this agreement and makes payment there will be no refund for any reason. By signing this agreement the parents and player agree to abide by all the above, and also agree to give Southland Baseball the right to talk to or release information to any or all college programs. Major League teams and scouts, and to put their child's profile/information on the Internet or in any Southland Baseball literature. You must sign below, or if under age 18, the parent or guardian of the participant must sign certifying that the above information has been read, complied with, and agreed to.

Parent or Legal Guardian Signature __________________________________ Date _____________

Players Name (print) ___________________________________________ Date ________________

Medical Information

Emergency Contact _____________________________ Phone # _____________

Is the participant taking any medication? (Yes/No) If yes, what? ____________________________

How often is this medication taken? _______________

What is the purpose of the medication? ________________________________________________

Is the participant allergic to anything and what? __________________________________________

Are there any physical limitations, special circumstances, or other information we should be aware of?

FAX to: 714-844-4726 or Mail Payment for $200.00 to:
Southland Baseball
PO Box 1239
Bellflower, Ca. 90706

If you have made an online payment mark here: (Yes/No) ________