PYF Player Registration Form

Pentucket Youth Football

2012 Player Registration Form

Registration Instructions:

- Fill in all fields on this form, Print using the PRINT button below, sign where indicated

- On Registration Day bring a printout of this form, a COPY of the child's birth certificate & payment in FULL

- Returning players may mail this form and payment to Pentucket Youth Football, c/o 89 West Main St.,

Merrimack, MA 01860

2012 Registration Dates:
6/17/2011, 5-8pm, Groveland Town Hall or 6/18/2011, 9-11am, Groveland Town Hall

YOU WILL NOT BE ALLOWED TO REGISTER WITHOUT A VALID BIRTH CERTIFICATE

First Name:	Last Name:
Street:	Town:		State:	Zip:
Telephone:	E-Mail:
Weight:
D.O.B.:		Grade As of September, 2012
Mother's Name:		Father's Name:
A & B team players must be 14 or younger as of September 1, 2012
C team players must be 12 or younger as of September 1, 2012

I hereby indemnify and hold harmless Pentucket Youth Football and its members from any claims my child or any of their heirs, assigns or representatives may have for injuries sustained during football practice and/or games. I am aware that football is a contact sport and, as such, injuries are likely to occur.

I give my child permission to participate in the Pentucket Youth Football program.

PARENT/GUARDIAN NAME (please print or type)

PARENT/GUARDIAN SIGNATURE: ___________________________

REGISTRATION FEE: $250, additional family members $125

New in 2011: Players will be receiving new practice jerseys, pants, girdles with pads, T-Shirts
and mouth guards all of which they may keep.

NO refunds will be made after the start of the season, 8/15/2011
Make checks payable to: PENTUCKET YOUTH FOOTBALL

I understand that the helmet, shoulder pads, game jerseys and game pants must be returned at the end of the season. Failure to do so will result in an assessment to the parent for the replacement cost.

PARENT/GUARDIAN SIGNATURE: ___________________________

As a parent or guardian of this child, I hereby give approval to their participation in this league. I agree to furnish a birth certificate and proof of primary insurance coverage for this child upon request of the league.
Also, in the absence of the parent/guardian I hereby authorize the Pentucket Youth Football
attending official to act on my behalf in securing and authorizing medical care for my child, in case of a medical emergency.

PARENT/GUARDIAN SIGNATURE: ___________________________