Release form
Warrensburg-Latham Junior Football League
A member of the Little Illini JFL League
2010 Season
Last Name________________________________________ First Name________________________________________ MI_____
Address______________________________________________ City_____________________________ Phone #______________
Zip__________ School_______________________________________ School Grade that player should be in this fall___________
Birth Date_____/_____/_____ Gender (circle one) M or F Emergency Contact # ________________________
Father/Guardian_____________________________________ Cell Phone__________________ Home Phone__________________
Mother/Guardian____________________________________ Cell Phone__________________ Home Phone__________________
Family Doctor________________________________________ Preferred Hospital_______________________________________
Insurance Provider__________________________________________ Group or Policy Number_____________________________
Medical History (Allergies, Previous Broken Bones, etc.)______________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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RELEASE TO PARTICIPATE:
I give my permission for _________________________________________ to participate in full contact football practice sessions and games sponsored by Warrensburg-Latham JFL during the 2010 football season. Further, I give my permission for my child to travel with, and participate in, any and all out town games scheduled by the Warrensburg-Latham JFL. I understand that no fees will be refunded after the first scheduled practice
RELEASE OF PERSONAL LIABILITY:
I agree not to sue and hereby release from liability the Board Members and Coaches of the Warrensburg-Latham JFL and the Board Member of the Little Illini JFL League in the event of any and all bodily injury, property damage or theft, or any other losses suffered by the registered player.
EQUIPMENT AGREEMENT:
I/We agree to return all equipment issued by the Warrensburg-Latham JFL at the close of the football season. Further, I/we agree to be financially responsible for new replacement costs of equipment not returned and/or excessively damaged.
RELEASE TO USE PHOTOGRAPHS:
I/We agree to release the Warrensburg-Latham JFL to use group and/or solo photographs of team players for promotional publication (such as, but not limited to, news papers, flyers, web page, etc.). Further, I/we agree to allow videotaping of team players for training and/or promotional purposes.
CONSENT TO AUTHORIZE EMERGENCY MEDICAL TREATMENT:
I/We authorize any and all Board members and Coaches to authorize emergency medical treatment, as deemed necessary by said Board Member and/or Coach, in the absence of the team player’s legal guardian.
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Signature of legal guardian______________________________________________________________ Date______/______/______
Copy of players birth certificate (required) received______ Fee paid with: a) check/mo #________________ or b) cash____________
Board member of the Warrensburg-Latham JFL must witness signature: Initials ________ Date ______/______/______
Helmet Size:________________ Jersey Size:_____________________ Shoulder Pad Size:________________________