Youth Football Registration Form - County Of Surry, The Department Of Parks And Recreation

ADVERTISEMENT

YOUTH FOOTBALL REGISTRATION FORM 
COMPLETE ONE FORM PER  CHILD 
 
Please check here if interested in camp:      (   )                                                                                            Fee _____________________ 
 
A PHYSICAL EXAM IS REQUIRED FOR ALL PARTICIPANTS AT LEAST EVERY TWO YEARS. 
 
Participant’s Name ____________________________________________________________________     Age ___________ 
 
Address ____________________________________________________________   Date of birth _______________________ 
 
                                 City _______________________________   State ___________   Zip ___________________    
 
Parent/Legal Guardian’s Name _________________________________________________________________________ 
 
Home Phone ______________________   Cell Phone ____________________   Work Phone ____________________ 
 
E­mail Address _____________________________________________________________________________________________ 
 
IN CASE OF EMERGENCY 
                Contact # 1                                                                                                          Contact # 2                          
                Name _____________________________________________________                           Name _____________________________________________________ 
 
                Address __________________________________________________                           Address __________________________________________________ 
 
                Home # ___________________________________________________                          Home # ___________________________________________________ 
 
                Cell # ______________________   Work # ____________________                          Cell # _____________________   Work # _____________________ 
 
                **************************************************************************************************************** 
 
                Participant’s Allergies: _____________________________________________________________________________________________________________ 
 
                Participant’s Medical Conditions: ________________________________________________________________________________________________ 
 
                MEDICATIONS CANNOT BE  GIVEN TO ANY CHILD OR ANYONE EMPLOYED BY THE SURRY COUNTY PARKS AND                       
                                                                                                  RECREATION DEPARTMENT. 
 
               Name of Participant’s Physician __________________________________________________________________________________________________ 
 
                Physician’s Telephone _____________________________________________________________________________________________________________ 
 
                **************************************************************************************************************** 
 
                                                                                          WAIVER OF LIABILITY RELEASE FORM 
 
I am aware of the nature of this activity and I hereby assume responsibility for  _________________________________________________ 
 
                                                                                                                                                                                                                                                                                  (Participant’s Name)  
to participate and to be photographed for publicity purposes.  I will not hold the COUNTY OF SURRY, THE DEPARTMENT  
OF PARKS AND RECREATION and/or its employees responsible in the case of accident or injury as a result of this              
participation.  I understand that this completed form must be in the possession of the Surry County Department of       
Parks and Recreation prior to participation in this program. 
 
Parent/Legal Guardian Signature __________________________________________________________________   Date ________________________________
 
 
FOR OFFICE USE ONLY 
 
 
Amount Paid _________________  (  ) M.O.  (  )  Cash  (  )  Check # ______________  Receipt $ ______________   Received by _______________   Date ______________ 

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Life
Go