ONLINE REGISTRATION
CHILD'S NAME
*
First Name
Last Name
DATE OF BIRTH
*
-
Month
-
Day
Year
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AGE AS OF 9/1/26
*
SCHOOL GRADE AS OF 9/1/26
*
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CONTACT
EMERGENCY CONTACT
*
EMERGENCY CONTACT NUMBER
*
-
Area Code
Phone Number
E-mail
MAY WE TEXT YOU?
*
YES
NO
HEALTH INSURANCE PROVIDER
POLICY NUMBER
GENERAL INFORMATION
Please mark any conditions applicable to your child's ability to participate
ASTHMA
USES INHALER
ALLERGIES
USES EPI-PEN
Does your child have any physical disability or health related issue that could prevent him/her from participating in contact football?
*
YES
NO
Please explain any special needs or conditions your child's coaches should be aware of.
Has your child played for any other Beaver County Youth Football League organization in the previous year?
*
YES
NO
If yes, with whom?
Registration Fee
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1st Child Registration
$
50.00
Registration for 1st child
2nd Child Registration
$
25.00
Registration for 2nd child
3rd Child Registration
$
25.00
Registration for 3rd child
Total
$
0.00
CONSENT
I consent to the taking and use of my child's photograph for the promotion of the Freedom Lil' Bulldogs football organization by way of website, multi-media, or written/printed material.
*
YES
NO
ACKNOWLEDGEMENT
I ATTEST THAT THE ABOVE QUESTIONS HAVE BEEN ANSWERED TO THE BEST OF MY KNOWLEDGE AND DO NOT HOLD THE FREEDOM LIL' BULLDOGS BOOSTER CLUB LIABLE FOR ANY MISREPRESENTATION OF THE ABOVE QUESTIONS.
*
PARENT/GUARDIAN FIRST NAME
PARENT/GUARDIAN LAST NAME
Signature
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