The Flag Football League of Kansas City

Player Registration & Equipment Order Form

PLAYER INFORMATION

* First Name:

* Last Name:

NAME PRONUNCIATION

This information is necessary so our PA Announcer properly announces your name. Please give the phonetic spelling of your child's name (first, last, or both if necessary)

Examples:

Name Pronunciation
---------------------------------------------------
Jorge Bonifacio...............BONE-ee-fah-see-oh
Neftali Feliz...................nef-tah-LEE Feh-LEEZ
Ryan Buchter..................................BOOK-ter
Sam Gaviglio.........................Guh-Vee-lee-oh
Mike Jirschele................................Jursh-LEE

Phonetic Spelling:

How are you registering:

If you are registering as a "Free-Agent"
the league will forward your name to
coaches who will contact you if they
have an available spot on their team.
You may also form your own team. The
league cannot guarantee that we will
get you on a team. It is ultimately
the responsibility of the player to
find or form a team.

If you are a member of a team,
list Head Coach's Name

(Last Name, First Name):

Player Address

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Birthdate:

Email:

* Gender:

* Grade (select the grade you will be in this fall):

Name of School Attending:

If school name is not listed, please type school name here:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

* EMail:

* Home Phone (Please enter in this format xxx-xxx-xxxx):

Work Phone (Please enter in this format xxx-xxx-xxxx):

* Cell Phone (Please enter in this format xxx-xxx-xxxx):

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone (Please enter in this format xxx-xxx-xxxx):

Work Phone (Please enter in this format xxx-xxx-xxxx):

Cell Phone (Please enter in this format xxx-xxx-xxxx):

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone (Please enter in this format xxx-xxx-xxxx):

* Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

Waiver and Release of Liability PLEASE READ THIS RELEASE, CAREFULLY, BEFORE SIGNING- In consideration of being a member of the Flag Football League of Kansas City (FFLKC), and for my child being able to participate in FFLKC sponsored tournaments, league play and any other flag football activities as a member of a FFLKC member team, the undersigned acknowledges, appreciates, and agrees that: 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. 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 participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately and provide a written report to the league office; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS FFLKC, and their officers, officials, agents, advisory boards, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. 5. I, the undersigned declare on my honor that I am a flag football player, and agree to follow the rules of the FLAG FOOTBALL LEAGUE OF KANSAS CITY, (FFLKC), obey my coach(es), team leader(s), tournament officials, and directors. My child is in good physical condition and has no disease or injury that would impair his/her doing his/her best in competition; or that could injure, impair or infect his/her team members or members of the opposition. 6. I hereby authorize any first aid, medication, medical treatment, or surgery deemed necessary in case of an emergency. I also authorize the attending medical personnel to execute on my behalf any permission forms and other appropriate medical documents and act on my behalf if I am not immediately available to do so. 7. I hereby consent to allow my picture or likeness to appear in any FFLKC official documents, news releases, sponsor advertisements, movie, and/or television coverage of FFLKC events in any manner direct or incidental to my participation in those events without compensation to me. 8. If you are registering as a "Free-Agent" the league will forward your name to coaches who will contact you if they have an available spot on their team. You may also form your own team. The league cannot guarantee that we will get you on a team. It is ultimately the responsibility of the player to find or form a team. 9. The league does not guarantee a number of games to be played or guarantee a number of games scheduled or played on the main field. 10. PETS ARE NOT ALLOWED AT THE PARK.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

I/we agree with the above *

NO PETS ALLOWED AT ANY OF THE FFLKC GAMES (by clicking this I agree to this statement) *

REGISTRATION FEE

Grade Level (select the grade you will be in this fall):

Registration Code

Enter 6-Character Code from the
advertisement if you have one

Code:

T-Shirt Size:

EQUIPMENT

The following equipment is required per grade level:

Pre-K: Mouthguard (t-shirt is included with registration fee.)

Kindergarten: Mouthguard (jersey & flag set is included with registration fee.)

1st Grade through 8th Grade: Jersey, Pants, Socks, Flag Set, Mouthguard

High School: Mouthguard (jersey, shorts, and flag set included with registration fee.)

Any equipment purchased outside the league must meet league approval.

Football Slotted Pants ($22.00):

Shorts (High School Players Only):

Football Jersey ($25 Each):

Jersey Number (we do not guarantee you'll get this number):

Name on back of jersey (add $6.00):

Socks - $7.00 per pair:

Flag Set - $12.00 per set:

Mouthguard - $5.00 each:

Official FFLKC Football - $30.00 each:

CREDIT CARD INFORMATION

Credit Card Type:

Name On Credit Card:

Credit Card Number:

CVV Code (3 or 4 digit security code):

Expiration Month:

Expiration Year:

Credit Card Billing Address Information

Street Address:

City:

State (2-letter Abbreviation):

Zip Code:

All sales are final after 7 days has passed from the time of payment.
Any refund requested within the 7 day period will be given in full.

If you are paying by credit card and have entered your information,
please click on the "Submit" button at the bottom of this page.

PAYMENT BY CHECK

If you would prefer to pay via check,
please follow the following steps:

1) READ ALL STEPS BEFORE CLICKING ON "SUBMIT" BUTTON BELOW

2) Make check out for total of the registration and equipment fees.

3) Make check payable to:

The Flag Football League of Kansas City
253 East Bridlespur Drive
Kansas City, MO 64114

4) Write the Entry ID number in the memo section of the check
(the Entry ID number will appear on the next screen when
you click on the "Submit" button)

5) Print your registration form. (You will be able to print
on the next screen)

6) Mail registration form along with check to the address above
in step #3.

Registration is confirmed once payment has been received. The FFLKC is not responsible for lost mail. All late fees are due if payment is not received on-time for any reason.

All sales are final after 7 days has passed from the time of payment.
Any refund requested within the 7 day period will be given in full.

Signature:

Date:

* indicates required fields

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Player Registration & Equipment Order Form