$35 For Football $25 For Cheer
2012
Application
Last Name :___________________ M.I.___ First Name :_____________________
D.O.B :____/____/______ Age :______ Grade :________
SSN :_____-____-______
Address :________________________ __________________ ____________
(Street) (City) (State)
_____________ Cell Phone :_________________ Home Phone :_________________
(Zip Code)
Work Phone :__________________
Parent / Guardian Name :_________________________
(Please Print)
Email Address :_________________________________
(Please Print Clearly)
_____________________ (Child Is Participating In Following) ___________________
[] AYF (Football) or [] AYC (Cheer/Dance)
___________________________(In Case Of Emergency) ________________________
Contact # 1
Name :______________________ Phone Number :_______________________
Address :_________________________________
Relationship :______________________________
Contact # 2
Name :______________________ Phone Number :________________________
Address :__________________________________
Relationship :_______________________________
List all medical needs & history below :_______________________________________
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X______________________ X_____________________ Date___/___/______
(Print Child Name) (Child Signature)
X______________________ X_____________________ Date___/___/______
(Print Parents Name) (Parent Signature)