Linglestown Football Association 2012 Registration Form

 

CHILD'S INFORMATION

LEVEL:   ----- SMURF PEEWEE PONY MIDGET CHEERLEADER    YEARS WITH LFA:  ---- 1ST 2ND 3RD 4TH 5TH 6TH 7TH 8TH 9TH 10TH    AGE AS OF APRIL 30TH: --- 5 6 7 8 9 10 11 12 13 14   GRADE THIS FALL:  ----- 1ST 2ND 3RD 4TH 5TH 6TH 7TH 8TH 9TH 10TH 11TH 12TH

CHILD’S LAST NAME:    FIRST NAME:    BIRTHDATE:  JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 28 30 31   2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

ADDRESS:    PHONE :   

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PARENT'S INFORMATION

MOTHER'S INFORMATION NAME:   PHONE:    MOBILE HOME WORK PHONE :   MOBILE HOME WORK ADDRESS IF DIFF ABOVE:   EMAIL:

FATHER'S INFORMATION NAME:   PHONE:    MOBILE HOME WORK PHONE :   MOBILE HOME WORK ADDRESS IF DIFF ABOVE:   EMAIL:

 

EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT:   PHONE NUMBER:     MOBILE HOME WORK

RELATIONSHIP: 

RELEASE OF ALL CLAIMS

We, the parents of the above-named child, in consideration of the permission granted to my child by Linglestown Football Association (LFA) to participate in the LFA football program during the current season, do hereby release and discharge LFA, its organizers, board members and officers from all claims, demands, actions, judgments and executions which the undersigned ever had, or so has, or may have, or claims to have, against LFA, its successors and assigns, for all personal injuries, known or unknown, and injuries to property, real or arising out of the above-named child’s participation in the above-described sports activities.  I/We, the undersigned, have read this statement and understand all of its terms.  I/We execute it voluntarily and with all knowledge of its significance on the date entered below.

 

DATE:   PARENT/GUARDIAN SIGNATURE:

DATE:   PARENT/GUARDIAN SIGNATURE:  

MEDICAL INFORMATION

I/We, the parents of the above-named child, hereby give my/our permission for him/her to participate in any and all activities of LFA during the current season.  I/We have been advised that LFA is not and will not be responsible for any medical expenses or other claims that may arise while my/our child is playing football or cheering under the auspices of LFA or during games, practices, or transportation to or from games or practices.  I/We hereby represent that my/our child is covered by medical insurance through the below-named insurance company and that said coverage will continue in effect during my/our child’s participation in LFA.  I/We further agree to furnish a certified birth certificate for the above-named child upon request of league officials.

Medical Insurance Company:  
Family Physician:                     
Allergies/Medical Conditions (e.g., asthma, etc.): 

DATE:  PARENT/GUARDIAN SIGNATURE: