Mailing Address Street 1: * Street 2: City: * State: * Ohio ZIP Code: *

Primary Email Address Email Address: *

Primary Phone Phone Number: *

Mother Full Name: Home Phone: Cell Phone: Work Phone: Email Address:

Father Full Name: Home Phone: Cell Phone: Work Phone: Email Address:

Emergency Contact Full Name: * Home Phone: Other Phone:

Insurance Information Carrier Name: * Policy Number: *

Doctor Information DR/Practice Name: * Phone Number: *

Dentist Information DDS/Practice Name: * Phone Number: *

Waiver of Liability

By checking this box and submitting this registration form, the parent, guardian, or custodian (responsible person) of children participating in the Jackson Youth Football Association activities do hereby release the association, its officers, directors members, coaches, and players from any and all liability for any injuries to parents, family members, or participants as a result of participation in association activities, including but not limited to games and practices. The responsible person also waives any liability resulting from association action in a situation involving a participant requiring emergency medical attention, as outlined below. The responsible person also understands that football is an inherently dangerous activity, with a great deal of physical contact between participants of different size and skill level. The responsible person also understands that association coaches are volunteers and do not guarantee any special level of expertise. The responsible person affirms that he or she has the authority to sign such a waiver of liability for the signer, child(ren), and other responsible person. Signature affirming this waiver of liability is required for association participation.

	Acknowledgment of Rules and Regulations
	Responsible party acknowledges and agrees to follow and be bound by the league written rules and regulations. These guidelines must be followed by the responsible parent and participating child(ren) in the league. The JYFA strongly suggests your athlete have a complete physical for this season.

	Emergency Medical Attention
	Should an emergency arise during an association activity and a responsible parent, custodian, or guardian is not present, the association will use reasonable efforts to secure emergency medical attention and to notify the appropriate family member immediately.

Responsible Person

I hereby affirm that all of the information on the registration form is true. I also give my permission to the association to use its best judgment in giving emergency medical attention to my child(ren). I also hereby waive any liability on the part of the association and others as outlined in the WAIVER OF LIABILITY. I also affirm that I have completely read and understand the WAIVER OF LIABILITY and association policies concerning eligibility and EMERGENCY MEDICAL ATTENTION.