Mid States Hockey Cheerleading

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CBC - Cheerleader Registration

CHEERLEADER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Birthdate:

Email:

* Name of Club Team:

* Sponsor:

* School Attending:

* Level:

* Grade:

PARENT/GUARDIAN

* Firstname:

* Lastname:

EMail:

* Home Phone:

Work Phone:

Cell Phone:

CHEERLEADER'S PHYSICIAN

* Physician Name:

* Office Phone Number:

* After Hours Phone Number:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone Number:

* Realtionship to Cheerleader:

* Health Insurance Carrier:

* Policy Number:

Allergic Conditions:

WAIVER INFORMATION

I, the undersigned parent or legal guardian, do hereby consent and agree that the above named minor may participate in the MID-STATES CLUB HOCKEY ASSOCIATION program, or any other sports program sponsored by the Club Team. It is agreed that the Association (League), Cheerleerleader Association or Club Team assumes no legal liability for injuries or other loss as a result of such participation. It is further agreed that this consent shall remain in full force and effect until such time as the undersigned parent or legal guardian shall notify the ASSOCIATION in writing of the abrogation or cancellation of this consent. I further understand that I must provide my own Medical Insurance Coverage. I further agree to abide by the Rules and Regulations and Bylaws of the Association as enforced by the Board of Directors and Officials of MID-STATES CLUB HOCKEY CHEERLEADER ASSOCIATION.

To be eligible to participate, a cheerleader must supply Mid-States club hockey association with a copy of her latest semester grade card. This includes the grade card at the end of the spring semester as well as the fall term grade card. A cheerleader must earn at least 3.0 units of credit per semester. Summer school classes can be included to meet the 3.0 units. Please see MSCHSA bylaws under 9.1

I/we agree with the above *

Signature:

Date:

* indicates required fields

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CBC - Cheerleader Registration