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:________________________