EmailMe Form - 2012 Tackle Football Registration

Child's LAST NAME *

Child's FIRST NAME *

Gender

Male

Female

Date of Birth (MM/DD/YYYY) *

School Player will attend in the Fall *

Grade Player will attend in the Fall *

Street Address *

City, State and Zip Code *

Name of Father

Name of Mother

or Name of Guardian

Home Telephone Number *

Cell Phone Number or Alternate Number *

Email Address

Emergency Contact Name *

Emergency Contact Number *

Emergency Contact Relationship to the Child *

Name of Insurance Carrier *

Any Medical Conditions *

Parent Acknowledgement of the Program/Rules *

I will be submitting my payment via paypal or check? *

Paypal (Visa/MC/Discover)

Check

How did you hear about us? *

If you are a returning player, which year did you last participate?

Comments Suggestions?

I consent to pictures of my child to be posted on the MPYFL Website *

Yes

No

Sibling Playing/Cheering *

Yes

No

Additional Comments

Jersey Number Pref #1

Jersey Number Pref #2

Jersey Number Pref #3

Jersey Size (ex: Y-M; A-L)

Please initial, stating you have read the Liability Release below and Agree with statement.

Liability Release:

I understand the nature and scope of the above listed program. I understand that there are risks and danger associated with the program. I understand that it is the function of Manassas Park Youth Football League, Manassas Park Youth Football League volunteer coaches to operate in order to guarantee that the safety of participants with respect to the activity(s). I also understand that each participant has the responsibility to exercise due care in the performance of the activity for the safety of himself/herself and the other participants. In consideration of my (the participant’s if under the age 18 and parent, legal guardian or legal custodian is signing for participant) being permitted to enroll in this activity, I hereby release, indemnify and hold harmless the Manassas Park Youth Football League and all volunteers from any and all claims, demands, costs, charges and expenses from harm, injury, damage or loss which may sustained by me (by participant if under age 18 and parent, legal guardian or legal custodian is signing for participant) as a result of or related to participation in this activity. *