Virginia City Middle School Football

Subscribe to our Newsletter

2017 Registration Form

Football $75

Cheerleading $75

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Birthdate:

Email:

Gender:

* 2016/2017 Grade:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

EMail:

* Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

* Medical and/or physical limitations or medications are as follows::

WAIVER and AGREEMENT INFORMATION

I hereby give permission for any and all necessary medical attention and treatment to be administered to my child/ward in an emergency such as an accident, injury, or sickness, etc., while s/he is under the direct care of the Virginia City Youth Coaching Staff and/or participating in any Virginia City Youth Football/Cheerleading activity, or event until such time as I may be contacted. In the event that I cannot be contacted, this consent serves as permission for my child/ward to receive any and all medical attention and treatment determined to be necessary by appropriate medical authorities and health professionals. I assume responsibility for the payment of any medical treatment provided to my child/ward (except to the extent and in the amount covered by accident or liability insurance when available). This consent is effective during the entire 2016 Virginia City Youth Football/Cheerleading Season.

IN CONSIDERATION OF my minor child/ward being allowed to participate in any way in the Virginia City Youth Football and Cheer activities, related events and activities, the undersigned acknowledges, appreciates, and agrees that:

1) The risk of injury to my child/ward from the activities involved in these programs is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
2) FOR MYSELF, SPOUSE/OTHER PARENT, AND CHILD/WARD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my child’s/ward’s participation;
3) I willingly agree to comply with the program’s stated and customary terms and conditions for participation. If I observe any unusual circumstance or have a significant concern regarding my child’s/ward’s readiness for participation in the program, and/or in the program itself, I will remove my child/ward from the participation and bring such circumstance/concern to the attention of the nearest league official immediately; and,
4) I myself, my spouse/other parent, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE THE other participants, sponsoring agencies, sponsors, coaches, league officials, the league itself, advertisers, and if applicable, owners and lessors of premises used to conduct any league event (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my child’s/ward’s involvement or participation in the Virginia City Youth Football and Cheer program, activities and/or events, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law;
5) I, for myself, my spouse/other parent, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releases from any and all liabilities incident to my child’s/ward’s, as well as my own, involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law;
6) I understand the seriousness of the risks involved in participating in this program, my personal responsibilities for adhering to rules and regulation, and accept them as a participant for myself and on behalf of my child/ward.

PLEASE READ THIS IMPORTANT INFORMATION AS A SIGNATURE INDICATES ACCEPTANCE OF THIS POLICY:
As the parent(s) and/or guardian of the above named child, I hereby give my permission to participate in any and all Virginia City Youth Football activities. I know that participation in football or cheerleading may result in serious injuries and/or death and that protective equipment does not prevent all injuries to the player. I hereby waive, release, absolve, indemnify and agree to hold harmless Virginia City Youth Football, the organizers, sponsors, supervisors, coaches, participants and persons transporting my child to and from activities from any claim arising out of an injury or death to my child whether the result of negligence or any other cause, except to the extent and in the amount covered accident or liability when received. I further authorize to have my child transported to the closest hospital should any injury require medical attention.

Virginia City Youth Football and Cheer Communicable Disease Policy: While the risk of one athlete infecting another with HIV/AIDS during competition is rare, there is a remote risk that other blood borne infectious diseases can be transmitted. The Nevada Athletic Commission and Nevada State Officials Association have determined that children with communicable diseases cannot participate in football or cheerleading.

Virginia City Youth Football and Cheer has a NO REFUND policy. No refunds will be given for any reason other than the inability to field a full team.

I agree to return all uniform and/or equipment deemed as property belonging to Virginia City Youth Football and cheer that is issued to my child in the same condition, except normal wear and tear. I agree to be legally and financially responsible for the care and return of the same. Replacement cost for said uniform and/or equipment is as follows: Helmet $80; Shoulder Pads $80; Pants $25; Jersey $65; Pant Pads $20; Cheer uniform (Shell & skirt) $65; cheer pompoms $25. I agree to pay all legal costs including but not limited to attorney’s fees and court costs if I fail to return said equipment by the established deadline at the end of the season. In addition to issued uniform and equipment, your registration includes: shorts, t-shirt, Individual & Team Photo and field costs.

I agree to pay a $35 returned check fee in addition to the full amount of the returned check in cash to Virginia City Youth Football.

I/we agree with the above *

* Print name for Signature after agreeing to waiver/agreement:

* indicates required fields

OUR SERVICES

LOCAL SPORTS

ELITE

2017 Registration Form