Delaware Valley 8th Grade Spring Football

MAGNOLIA TROJAN FOOTBALL CLUB 2013

Head Coach Mike Smith 856-373-6643

Asst. Head Coach Brian Yackle 856-229-4073

Childs Name:_________________________________________________ Team:___________________________

Address:___________________________________________________ School/Grade:_______________________
Phone #:_____________________________ Present Age:_________ Birth Date:____________________________
Name(s) of Parent or Guardian(s):__________________________________________________________________
Emergency Contact: _____________________________ Relationship: ______________ Phone________________
Email:________________________________________________________________________________________
Insurance Carrier: ________________________ Policy #:________________ Name of Insured_________________
Family Physician: _____________________________________ Physician Phone___________________________
Medical History (Detail all that Apply)
Allergies_________________________________
High Blood Pressure__________________________
Asthma__________________________________
Recurring Sore Throat/Ear Infection _____________
Convulsions______________________________
Medications currently taking ___________________
Diabetes_________________________________
Injury currently being treated ___________________
Migraines________________________________
Heart Troubles_______________________________
Contact Lenses____________________________
Epilepsy/Fainting Spells_______________________
Mental Disorders__________________________
Other______________________________________
Medical conditions currently being treated ___________________________________________________________
Daily medication and schedule ____________________________________________________________________
I, the parent/guardian of the above named child, hereby give my consent to his/her participation in any football activities
during the coming season. I also agree to hold harmless the Trojans, their agents and coaches should any injury result to the
above named child during participation in any football activity. I also give the Trojans, their agents and coaches
permission to see medical treatment should an emergency arise.
Equipment: I agree to return upon request all equipment issued to my child in as good condition as when he/she received,
except for normal wear and tear. I further agree that this equipment will ONLY be worn during games and practices unless
otherwise specified by the Trojans. Failure to comply will result in dismissal from the team. I also agree that should any
equipment issued to the above named child be lost or misplaced, I will be personally liable to the Trojans for replacement
costs of said equipment and understand that legal action may be taken to reclaim any equipment. I agree to provide the
Trojans with the above named childs ORIGINAL birth certificate (and a sport physical, may this be required by the
league).
Helmet Size
Jersey
Girdle Size
Jersey #
Last Name on Jersey

_______________
_______________
_______________
_______________
_______________

Payments:

Deposit
Team Fitting
March 1st
Total Due

$25.00
$50.00
$50.00
$125.00

I hereby give permission to the Trojans to use any photos, videos or other media of my student athlete for the purposes of training,
recruiting and/or publishing by and for use on the Trojans website and/or other social media. To preserve the privacy and rights of the
student athletes no names will be disclosed in connection with any photos, videos or other media used on the Trojans website and/or
other social media.
I have read and understand the preceding Parental Consent and Release of Liability. I have also received a copy of the by-laws and
agreed to abide by these by-laws.

Name (Print)___________________________ Signature__________________________________ Date_________

Witness Name (Print)_________________________Witness Signature____________________________________