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 # _____________________
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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 _____________________________________________________________________________________________________________
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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 ______________