CUMBERLAND MIDGET FOOTBALL

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WELCOME TO CUMBERLAND MIDGET FOOTBALL & CHEERLEADERS SIGN UPS

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Gender:

Grade:

* High School Sending District:

PARENT/GUARDIAN #1

First Name:

Last Name:

E-Mail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

First Name:

Last Name:

E-mail:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

BY SIGNING THIS RELEASE, I WILL CONSENT TO ALLOW HIM/HER TO PARTICIPATE IN THE LEAGUE AND ALSO VERIFY THAT ALL THE INFORMATION IS CORRECT. IN THE INVENT OF A ACCIDENT WHERE MEDICAL ATTENTION IS NEEDED AND I AM NOT AVAILABLE. I GIVE CONSENT TO TREAT MY CHILD, I UNDERSTAND THAT CUMBERLAND FOOTBALL MIDGET LEAGUE INSURANCE IS A SECONDARY INSURANCE AND IS ONLY TO COVER WHAT YOUR PRIMARY INSURANCE WILL NOT.

I/we agree with the above *

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WELCOME TO CUMBERLAND MIDGET FOOTBALL & CHEERLEADERS SIGN UPS