MAYAA YOUTH Football

Athlete Information

Player Name*

First NameLast Name

Guardian / Parents Names*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Home Phone*

Format: (000) 000-0000.

Cell Phone

Format: (000) 000-0000.

E-mail*

example@example.com

CoachingFundraising

Emergency Contact & Health Insurance Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Format: (000) 000-0000.

Yes

Insurance Carrier

Name of Policy Holder

Subscriver ID/Group Number

Card Number / Card Date

YesNo

Please describe*

AUTHORIZATION
For medical treatment of minors
If your child needs medical, dental, health or hospital services, under the law, you as
parent/legal guardian must give permission. Naturally, if you are with your child you can
give permission as the need arises. You can prepare for those unexpected times when you
are not with your child by filling out this authorization form. Using this form, you can give
permission to other adults to act for you, in your absence, regarding treatment of your child.
This is a legal document. After you complete this form, give a copy to each adult you have
named to act on your behalf. If your child needs unexpected medical treatment, the
responsible adult should present this document to the appropriate person/physician, dentist
or hospital representative.
When a true emergency exists a child may be treated without parental consent. This will
happen when a physician determines that the child needs immediate medical care and that
an attempt to obtain parental consent would result in a delay, which would increase the risk
to the child’s life or health.

Name of Physician / Emergency Medical Care Facility

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

RELEASE OF LIABILITY – READ BEFORE SIGNING
In consideration of being allowed to participate in any way in the NORTHEAST YOUTH FOOTBALL LEAGUE (NYFL)
program, its related events and activities, I, the undersigned, acknowledge,
PARTICIPANTS NAME
appreciate, and agree that:

1. The risk of injury from the activities involved in this program is significant, including the potential for permanent
paralysis and death, and while particular skill, equipment, and personal discipline may reduce this risk, the risk of
serious injury does exist.

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both know and unknown, EVEN IF ARISING FROM THE
NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I
observe any unusual significant hazard during my presence or participation, I will remove myself from
participation and bring such to the attention of the NYFL Board of Directors immediately; and,

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE,
INDEMNIFY, AND HOLD HARMLESS THE NORTHEAST YOUTH FOOTBALL LEAGUE (NYFL), their officers,
officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if
applicable, owners and lessors of premises used for the activity (“RELEASEES”), WITH RESPECT TO ANY AND ALL
INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARRISING FROM THE
NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING
IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT AN INDUCEMENT.

YesNo

Confirmation E-mail*

example@example.com

Signature*

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE(UNDER AGE 18 AT TIME OF REGISTRATION) This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.

FlagJuniorsSeniors

Players Birthdate

Date

Current Age, Current Grade

Player Age on Sept 1 current year & Expected Grade Sept 1 current year

I blanks being the natural parent/legal guardian of blank know of no medical reason prohibiting my child from participating in the NYFL Tackle Football
Program. I am aware that any sports program, including the NYFL program, bears some risk to
a participant’s health. However, I hereby release the NYFL, its directors and any independent
contractors of any liability and/or negligence claims resulting from my child’s participation in
the NYFL program.

Signature

Copy of Birth Cert., Report card with current grade

MAYAA Youth Football