CORDOVA JR. LANCERS FOOTBALL AND CHEER

REGISTRATION AND LIABILITY FORM

2008

Athlete’s Name______________________________ School (in fall) _______________

Home Address ______________________________ Email _______________________

Home Phone _________________________ Cell Phone _________________________

Birth Date __________ Age on August 1^st, 2008 ______ Grade in School(in fall) ______

Mother/Guardian Name____________________________________________________

Father/Guardian Name ____________________________________________________

In Case of Emergency _________________________ Phone ______________________

Health Insurance _________________________________________________________

Physician’s Name___________________________ Number ______________________

Allergies to Medicines/Foods/Bee Stings ______________________________________

Has athlete had any serious illness, surgery, or injury? If yes, please describe and provide dates.

________________________________________________________________________

List any medication(s) currently taking:

________________________________________________________________________

I understand that there are risks and physical injury to the activity of football and cheerleading. In recognition of this acknowledged risk of injury, I knowingly and voluntarily waive all rights and/or causes of action of any kind, including any and all claims of negligence arising as a result of such activity from which liability could accrue to Cordova Jr. Lancers Football and Cheer, its officers, agents, employees, coaches, sponsors and all affiliated entities. I hereby agree to release and hold Cordova Jr. Lancers harmless of all liability, and hereby acknowledge that I knowingly and voluntarily assume full responsibility for all risks of physical injury arising out of active participation in football and cheerleading on behalf of the athlete.

I am aware that this is a release of liability and an acknowledgement of my voluntary and knowing assumption of the risk of injury. I have signed this document voluntarily of my own free will in exchange for the privilege of my athlete’s participation.

The above named athlete has my permission to participate in all Cordova Jr. Lancers Football and Cheer events. I warrant the above information is complete and correct. I hereby authorize the event directors or their agent to act on my behalf to provide emergency medical treatments to myself of my athlete. I further release Cordova Jr. Lancers Football and Cheer of all liabilities associated with me or my athlete attending any Cordova Jr. Lancers Football and Cheer events. I also give Cordova Jr. Lancers Football and Cheer permission to use photos/videos of my athlete in or on any form of advertisement.

I understand that any fees paid are non-refundable based on the guidelines outlined in the Cordova Jr. Lancers Member Handbook, 2008 Edition, and such stated fees does not guarantee my child a position on the Cordova Jr. Lancers Football or Cheer Teams. I understand that all fees are due based on specific deadlines. Any delay or refusal to pay such fees may prevent my athlete from participation in organizational activities or may cause my athlete to be dismissed from the organization.

Print Parent/Guardian Name ______________________________________________

Parent/Guardian Signature _______________________________________________

Date Signed ____________________________

For Official Cordova Jr. Lancers Football and Cheer Only

Non-refundable amount paid __________ Date __________ Received by (initials) _______________

Registration amount paid _____________ Date__________ Received by (initials) ________________

Original Birth Certificate ( )YES ( ) NO ____________________________________________

Physical Release Form ( ) YES ( ) NO Athlete’s Weight ________________

Address Verification ( ) YES ( ) NO Athlete’s Height ________________

Parent Code of Conduct ( ) YES ( ) NO T-Shirt Size ____________________

Athlete Code of Conduct ( ) YES ( ) NO

Team/ Squad Assignment based on athlete’s birthday as of 8/1/2008:

JPW ( ) PW ( ) JMID ( ) Mid ( )