Wallkill Valley Junior Football Association, Inc.

Football and Cheerleading Registration Form

First Name:___________________ Last Name:_______________Birthdate:_______________

Address:______________________Age as of 10/30/2010_______App. Weight:____________
Day Phone #:_______________Eve Phone#____________________Cell #________________
Email Address:__________________________Head Measurement for Helmet Size:_________
School:__________________________ Grade Entering in Fall 2010:_____________________
Family Physician:_________________ Physician Phone #:_____________________________
Please indicate specific medical allergies, chronic illnesses, or other medical conditions the coaches/medical personnel
should be aware of in case of emergency.
Emergency Contact Name:_____________________Relationship:_______________________
Emergency Contact Phone #’s(Specify Type):________________________________________
As a parent/guardian of the above mentioned child, I give permission for the child to be a candidate for the participation in the
Wallkill Valley Junior Football Organization for the period of July 1, 2010 till June 30 2011. The child is a permanent
resident of Franklin, Hamburg, Hardyston or Ogdensburg, NJ. I hereby waive and agree to hold the club harmless of any
claims arising from participation in the league programs and assume all risks and hazards incidental to such participation,
including transportation to and from the activities. The organization carries limited medical insurance which is intended to
supplement your primary insurance. In the event that your child requires medical attention resulting from physical injury, an
official of this organization must be notified immediately and our insurance carrier’s claim form must be completed within ten
days of such inquiry.
Upon request, I agree to return the uniform and other equipment issued to the child in as good as condition as when it was
issued, except for normal wear and tear during the season. If the uniform or equipment is not returned, I agree to pay this
organization the full amount of its replacement costs.
As parent/guardian, I agree to abide by the Wallkill Valley Junior Football Association, Inc. “Code of Conduct”.
As parent/guardian I understand that my registration fee is a “non-refundable” fee.

Wallkill Valley Junior Football Association, Inc. has permission to use my child’s name, likeness, image, voice and or
appearance, as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images and the like, taken
or made on behalf of the Wallkill Valley Junior Football Association, Inc. programs or activities. I agree that the Wallkill
Valley Junior Football Association, Inc. have complete ownership of such pictures, etc. including the entire copyright, and
may use them for any purpose consistent with the missions of the Wallkill Valley Junior Football Association, Inc. These uses
include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications,
advertisements and any promotional or educational materials in any medium now or later developed, including the internet. I
acknowledge that I will not receive any compensation for the use of said pictures, etc. and hereby release Wallkill Valley
Junior Football Association, Inc. and its agents and assigns from any and all claims which arise out of or are in any way
connected with such use.

I have read, understand and agree with the above consents, waivers and releases.
Parent/Guardian Signature:_________________________________________________________________

We receive NO financial support from the towns we receive participants from and we cannot fully
meet our goals without the help of you, the families. With this in mind, be aware that fundraising is
MANDATORY and all parents/guardians are expected to help support the League by volunteering at a
Committee. Each Committee has it’s own area of specialty in hopes that everyone can find a niche to
their liking and availability.

PAYMENT:
Date Received:____________
Amount: _________________
Type of Payment: Cash Check Credit Card (Circle One)
Credit Card Info: Type/ MC Visa
Name on CC:____________________CC#:__________________________Sec Code:____ Exp Date:_____
Billing Address:________________________________________________Account Zip Code:_______