(**This form must be sent in with registration if playing up 2 age group levels )

Commonwealth of Pennsylvania

County of _________________

I, ________________________, acknowledge that my child, ____________________, is participating on a team and playing in an age group older than said child’s actual playing age group. 

I further understand that there are possible risks inherent in my child playing on a team and in an age group with older players and with that understanding I willingly assume any liability of my child participating in this manner.

Witness my hand and seal this ______ day of ______________, ______.

________________________

Signature of parent

________________________

Print parent’s name

Sworn to and subscribed before me,

A notary public, the day and year set forth above.

________________________

Notary Public

My commission expires: