Love Gospel Assembly
2323 Grand Concourse
Bronx, N.Y. 10468
(718) 295-6367 (347) 945-0381
Bishop Gerald J. Kaufman Jose A. Rodriguez Bishop Ronald L. Bailey
Founder Commissioner Senior Pastor
Which division did you play for last year? (Check one) Alpha ___ Minor___ Major___ Senior___
Player’s Full Name: _____________________________________________
Date of Birth (mm/dd/year): _________/_________/_________ Age ________
Mailing Address: ___________________________________ Apt #_______ City__________
State______________ Zip Code ______ E-mail___________________________________
Home Phone (____) ____________________ Cell Phone ( ) ____________________
Parent's) Full Name: ____________________________________________________________
I /we will submit a copy of birth certificate, medical form, (1) picture and the registration fee.
(No refunds will be issued)
Make checks or money orders payable to: Love Gospel Assembly
In case of emergency, Contact: ____________________________Tel.___________________
Waiver of Liability
We / I the parent's) /guardian of _____________________________ candidate for a position on the LGA Baseball Academy, hereby give the approval to participate in any and all activities. I/We assumed all risks and responsibilities of any incidental hazards from participation, including transportations to and from the Academy’s activities. I/We also do hereby waive release, absolve, indemnify and agree to hold harmless Love Gospel Assembly Youth Baseball Academy, Love Gospel Assembly Inc., The Organizer, The Commissioner, Supervisors, Sponsors, Participants and persons transporting my /our Children) to and from the Academy’s activities for any claim's) resulting in a injury, whether by the result of negligence or any other cause except to the extent and in the amount covered by accident and /or liability insurance .
I/We, read and understand all the above.
Signature of Parent or Guardian: ___________________________________
Date_________________________
Receipt Number #_____________ Season________________