Football/Cheer Registration Form

Varsity Ages 10-12

JV Ages 7-9

Instructional Flag Age 5-7

Childs Full Name*

First NameLast Name

Childs Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Childs Birthdate*

Date

SCHOOL ATTENDING AND GRADE*

School District AttendingGrade going into

Tackle football (cant turn 13 before 10/31/25)Flag football (age5-7) (cant turn 8 before 10/31/25)Cheerleading (cant turn 13 before 10/31/24)

Please select one of the following...*

Preferred Jersey number ( Please List 3 with a , Between e.g. 1, 23, 56) *number not guaranteed

Parent/guardian Name*

First NameLast Name

Phone Number*

Format: (000) 000-0000.

Medical History. PLEASE LIST ALLERGIES, MEDICATIONS, SPECIAL CONDITIONS, ETC. Mark N/A if none applies.*

PREFERRED PHYSICIAN:

NamePHONE

PREFERRED DENTIST:

NamePHONE

PREFERRED HOSPITAL FILL IN
INSURANCE PROVIDER FILL IN

Medical Authorization

GRANT CONSENT: In the event reasonable attempts to contact the parents or guardians have been unsuccessful. I hereby give my consent for (1) the administration of any treatment deemed necessary by preferred Dr. or preferred dentists or in the event of designated Dr. or Dentist is not available, by another licensed physician or dentist; and (2) the transfer of the child to preferred hospital or any hospital reasonably accessible. NOTE: this authorization does not cover major surgery unless the medical options of two other licensed physicians or dentists, concurring in necessity for such surgery are obtained BEFORE the surgery is performed.

Select YES or NO to Grant Consent

YesNo

REFUSAL OF CONSENT: If consent is refused you are stating the following: I do not give consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish that Southington Little Wildcats take no action or perform the following actions designated below.

Fill in your Instructions to be followed in the event of an emergency. Only fill in if you have specific instructions and did not grant consent for emergency medical treatment.

Emergency contact: In event of an emergency contact #1 will be notified. Contact #2 will be called if the first is unavailable.*

Rows	Full Name	Contact Number
1
2

Upload a photo of birth certificate if this is a first year registration.

FEES

There is a Registration Fee of $100 per child due immediately upon registration. This fee is not available to be paid via fundraising.

There is an Additional $60 uniform fee per child. This fee can be fundraised for. It is due by July 1st. Once uniforms are ordered this money is non refundable.

Fees can be paid via venmo, cash or check.

For Venmo, search @Little-Wildcats or Justin Kren

Checks made out to Southington Little Wildcats

We will have an in person registration to accept cash or check on June 1st from 11-12:30 at the football field.

You can also contact Desirea Livezey, Amanda Powers or Dottie Kren to make arrangements for payment submission.

RELEASE OF CLAIMS

I am the parent/guardian of the above-named child who wishes to participate in the activities organized by the Southington Little Wildcats (SLW). I believe that my child is in good health and that there is no health or medical reason why my child cannot or should not participate in strenuous physical activity. I understand that it is my responsibility to have my child examined and cleared for participation in sporting activities, and I agree that the SLW has no duty to ascertain my child’s health or physical limitation or conditions.

I also understand that all sports including football/cheerleading involve the risk of injury, and I agree to assume the risk of injury to my child or to me resulting from my child’s participation in this program. In exchange for the SLW allowing my child to participate in it’s activities, I hereby waive and release all claims that my child or I may have or claim to have arising out of my child’s participation in all activities associated with the SLW. In consideration of being allowed to participate on behalf of SLW and related events and activities, the undersigned acknowledges, appreciates, and agrees that participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist, and I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation, and , I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately. This waiver and release extends to not only the SLW, but also it’s 1) affiliated organization 2) team sponsor 3) employee’s or volunteers (including without limitation managers, coaches, assistants) 4) officers, directors and board members and 5) owners or occupiers of land upon which activities may take place.

Signature*