Clone of Girls Flag Football Registration Form

The City Of Riviera Beach Little Chargers Instructional Football Clinic Registration Form
Please complete all required fields*
Annual Physical*

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Birth Certificate*

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Participant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residence

ResidentNon-Resident
Gender*

FemaleMaleN/A
T-Shirt/Jersey Size
Parent/Guardian Name*

First NameLast Name
Relation
Cell Phone Number*
Please enter a valid phone number.
Alternative Number
Please enter a valid phone number.
Parent Email*
example@example.com
Insurance Card*

Please upload the front of insurance card
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Proof of Residence

Proof of Residency (Utility Bill, Cell Phone Bill, etc.)
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Emergency Contact*

First NameLast Name
Relation
Emergency Contact Cell Phone Number*
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Parental/Guardian Consent
PARTICIPANT HOLD HARMLESS: As a condition of participation in City of Riviera Beach recreation programs, the undersigned agrees that in the event of disablement, injury or diseases of a temporary or permanent nature incurred by the participant while in the program, that all claims or liabilities are waived against the City of Riviera Beach Parks & Recreation Department, City of Riviera Beach, Florida and/or employees thereof and the undersigned does hereby assume said risk as one of the ordinary risks of participation in said program, and consequently holds the City of Riviera Beach harmless in the event of disablement, injury or disease named by the undersigned in the program.
Signature*

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Date*

MonthDayYear
Date
Register and pay for all youth and adult classes/activities can be made in person at the Parks and Recreation Department located at 2409 Ave H West. Register Early due to limited space!

It is mandatory to submit copies of: birth certificate, annual physical (must be current), proof of health insurance and utility bill (Residents of Riviera Beach ONLY) as required by the programs you register for.

Registration Payment can be made by: CASH, MONEY ORDER, or CREDIT CARD – NO CHECKS.

Please make money orders payable to the City of Riviera Beach.

Form must be completed in its entirety; all information is required at time of registration. Incomplete registration forms will not be accepted

REFUND POLICY:

Administration fee before season starts is $15.00 or 15% whichever is less

0% Credit or refund after 2nd class

Full Refund will be issued if class is cancelled.

No Refund will be issued if notified after the session has begun. (All Programs)

REFUND: Please allow 30 days to receive refund in mail.

Must return original receipt to 2409 Ave H West.

Must have mailing address and a contact number on back of receipt.

NOTE: By signing this form you acknowledge and agree the terms and conditions of the document.

CITY OF RIVIERA BEACH - PARKS AND RECREATION

2409 Ave H West, Riviera Beach, FL 33404

Phone: (561) 845-4070 Email: Parks@rivierabeach.org

Office Hours: Monday - Friday: 8:30 AM to 5:00 PM
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Little Chargers Football Registration Payment for The City Of Riviera Beach Little Chargers Football Clinic.
$55.00 Little Chargers Football Registration

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The City Of Riviera Beach Little Chargers Instructional Football Clinic Registration Form

Please complete all required fields*

Parental/Guardian Consent