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Youth Athletic Registration Form

  1. To be eligible to participate in the Pearisburg Recreation Department Programs each player must have submitted to the Town of Pearisburg, this form completely filled out and properly signed attesting the player's parents consent to his/her participation.

  2. Please Select a Program*

  3. Shirt Size*

  4. I give my consent and approval to the participation of the player named above to play the above chosen sport. I will not hold the Town of Pearisburg, authorities, and coaches responsible in the event of accident or injury as a result of participation. I further agree, that as a parent I will conduct myself in a sportsmanship like manner and will not criticize coaches, players or officials. Any questions, concerns or complaints about the program will be directed only to the Recreation Director. I also understand that failure to do this could result in the suspension of me or my child from the sport.

  5. Photo Permission*

    I give permission for the Town of Pearisburg to use my child's picture on the Town's website, Facebook page and/or local paper.

  6. Leave This Blank:

  7. This field is not part of the form submission.