Physical Residency Form printable pdf download

Western Ohio Junior Football Conference

Residency and Physical Form

(Please Type or Print)

Organization: ________________________________________

Bantam

3rd

Team Color (if applicable):_______________________________

PLAYER/PARTICIPANT INFORMATION

NAME (Last, First)

AGE ON SEPT 1ST

DATE OF BIRTH

STREET ADDRESS

PHONE NUMBER

CITY/STATE/ZIP CODE

EMERGENCY PHONE NUMBER

FATHER’S NAME

MOTHER’S NAME

PHYSICIAN’S NAME

PHYSICIAN’S PHONE NO.

GRADE

PUBLIC SCHOOL DISTRICT

SCHOOL NAME

MEDICAL INSURANCE?

YES

PARENT OR GUARDIAN…Please read the following and sign at the “X”

I/We hereby make application for the above named minor to participate in this youth football program and the Western Ohio Jr. Football

Conference (WOJFC) for the upcoming football season. I/We also fully understand the risks involving personal injury, which may arise

during the course of the football program and voluntarily assume any and all such risks. I/We hereby release the WOJFC and all its

member organizations, administrators, officials, sponsors, coaches, supervisors, volunteers and facilities of any and all injuries that may

occur at all games, practices, and during travel to and from the same.

II.

I/We agree to abide by all Rules, Bylaws, decisions and interpretations of the WOJFC and/or this youth football organization for which the

minor is registered. I/We also agree that prior to the first scheduled practice of the upcoming season that I/We have read and agree to

comply with the WOJFC Parent’s Code of Ethics provided at . Failure to abide by and comply with any of the aforementioned

items could result in penalties up to and including the permanent expulsion from the WOJFC.

III.

I/We understand and accept the responsibility for the return or replacement of any and all equipment and/or properties of the WOJFC

(and/or your specific member organization) that are loaned or placed in the above named minors and/or my care.

IV.

I/We understand that the WOJFC mandates that all players must reside within the public school boundaries (or boundaries otherwise

approved by the WOJFC) of their respective organization as of the date of the first day of Practice (the last Monday in July). Your

signature below certifies that the information provided above is complete and accurate. Violation of this residency rule could result in you

and your child’s immediate suspension from the WOJFC and the possibility of permanent removal from participation in the WOJFC. In

the case of divorced and/or separated families, the school district of the parent with legal custody (Residential Parent) and/or designated by

the Courts will be used.

PARENT/GUARDIAN SIGNATURE

DATE

PHYSICIAN’S STATEMENT…Please complete the following and sign and date at the “Xs”

*Date Physical was preformed

: ________________________________

I certify that the above named child has completed a sports physical in the calendar year of the season which he is to participate and

that this child is physically able to participate in the athletic activities for which this physical was administered.

Physician’s name: ______________________________

X______________________________________

Address:______________________________________

Physician’s Signature

_____________________________________________

X______________________________________

Telephone#:___________________________________

Date

(Top sheet (original) - WOJFC copy; Middle sheet - Club copy; Bottom sheet - Team copy)

Version 4/17/2016

Physical Residency Form

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