NORTH CROWLEY PANTHERS PEEWEE

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CHEERLEADING (Ages 4-13)

CHEERLEADER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

Zip Code:

* Home Phone:

* Birthdate:

* Age:

* Gender:

Grade:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

* EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

Doctor's Name::

Doctor's Phone:

* List any medical conditions that may affect participation::

WAIVER INFORMATION

PARENT MEDICAL AUTHORIZATION:

I, the parent/guardian of the above named child, do hereby give permission to the managing personnel or other association representatives to authorize and obtain medical care for the above named child, from any licensed physician, EMT, hospital, or medical clinic, should the participant become ill or injured while participating in league sponsored activities when neither parent is available to grant permission for emergency treatment.

I agree with the above statement: *

PARTICIPATION ACKNWLEDGEMENT

I, the parent or guardian of the above named child, do hereby give approval for his/her participation in any and all North Crowley Youth Association sponsored activities during the current season. I assume all risks and hazards incidental to such participation including transportation to and from activities, and do hereby waive, absolve, indemnify and agree to hold harmless the North Crowley Youth Association Board of Directors, coaches, organizers, sponsors, supervisors, participants and person transporting the participant to and from activities, for any claim arising out of an injury to the participant, except to the extent of the amount covered by accidental and/or liability insurance by the association.

I agree with the above statement: *

INTERNET/NEWSPAPER RELEASE

I authorize North Crowley Youth Association to publish pictures and/or names of my child/children participating in North Crowley Youth Association games and/or activities on the North Crowley Youth Association website, www.ncya.org and/or local newspaper.

I agree with the above statement: *

PAYMENT OF FEES

I, the parent or guardian of the above named child, do hereby acknowledge and accept the fees required to participate in NCYA programs. I understand that failure to meet payment deadlines could result in a delay in ordering the above named child’s uniforms.

I acknowledge that $50 registration fees are non-refundable. I understand that once a NCYA uniform has been ordered for the above named child no refunds will be made.

I understand that the standard NSF rates apply for all insufficient checks returned to North Crowley Youth Association.

I agree with the above statement:

* indicates required fields

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CHEERLEADING (Ages 4-13)