PLANO YOUTH TACKLE FOOTBALL P.O. BOX 214 PLANO, IL 60545

PLAYER/CHEERLEADER INFORMATION/PERMISSION/WAIVER FORM

REGISTRATION DATE - MARCH 15, 2003

RETURNING PLAYER 10AM - NOON. NEW PLAYERS 1PM -3PM

Child’s Name: _____________________________________________________________________________________________

Address: _________________________________________City: __________________ State: ______ Zip Code: _________

Age as of 9/1/03: _________ Birthdate: _________________ Current Grade ___________ Sept. 03

PARENT/GUARDIAN INFORMATION:

Parent(s)/Guardian(s) Name:___________________________________________________________________________________

Address:______________________________________________City: ______________ State: ____ Zip Code:____________

Parents/Guardian Home Phone: _______________________________Work/Cell Phone: _______________________________

MEDICAL INFORMATION:

Emergency Contact (other than father & mother): ______________________________Phone Number: ___________________

Doctor’s Name: ______________________________________________________________________________________

Doctor’s Phone Number: ________________________________Hospital(s) of Choice: _________________________________

Insurance Company Name/ID Number: ________________________________________________________________________

Allergies/Medical Conditions: _________________________________________________________________________________

Prescriptions:________________________________________________________________________________________________

Permission

I/We as parent(s)/guardian(s) of the above child give my/our permission for him/her to participate in the Plano Youth Tackle Football program. I/We agree to abide by all rules established. I/We agree to return or replace all equipment issued to our child at the end of the season. I/We agree to support our child in an adult and sports person like manner.

Parental Rules for Game

I/We understand that in order for my child to participate in any game, a parent/guardian MUST be present during the entire game and sign my/our child in at half time of the previous game and at half time of their game. I also understand that if I/We are unable to attend that we MUST fill out a TEMPORARY PARENT SUBSTITUTION REQUEST, and return it to the Parent Rep. or Coach prior to the game.

Waiver

I/We as parent(s)/guardians of the above child, have our own insurance policy and are satisfied that it is sufficient to cover my/our child’s participation in the program. I/We understand that this is a contact sport with strenuous physical activity. I/We are satisfied that my/our child is in good physical health and able to participate. I/We agree to pay for all medical bills which may result from participation in the program. I/We agree not to hold liable for any injury my/our child may incur while participating in any league sponsored activity, any officer of the Tri County Football League or Plano Youth Tackle Football League (past or present) or any volunteer and or coach. I/We also agree no to hold liable for injury, the Board of Education, or any member of the Plano School District #88 or it affiliates.

Sports Physical

Tri-County Football and PYTF require that each participant has a sports physical or sign a waiver of this requirement.

( ) Yes, our child has a current sports physical that we are submitting

( ) No, our child does not have a sports physical and we refuse and waive all liability as signed below.

I/We as parent(s)/guardian(s) of the child listed agree to all conditions listed, and that all information listed is correct.

Parent(s)/Guardian(s) Signature(s):___________________________ ______________________________ Date _________

NEW PARTICIPANTS NEED: ` CURRENT PHOTO ` COPY OF BIRTH CERTIFICATE RETURNING PARTICIPANTS NEED: ` CURRENT PHOTO