Form 1

AMERICAN YOUTH FOOTBALL FORM (3)

AMERICAN YOUTH FOOTBALL REGISTRATION

Step 1 of 6

Minor Name (Participant)*
First Last
Parent/Guardian Name (Participant)*
First Last
Association: Berkeley Jr Jackets
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Participant forms must be presented to the Coach or Team Administrator for inclusion in the team book. Team books must be presented for compliance verification prior to participation in any American Youth Football, Inc., American Youth Cheer dba, Regional, National sanctioned event. All rostered Participants must complete the following paperwork in order to be allowed to participate in any American Youth Football, Inc., American Youth Cheer dba, Regional, National sanctioned event.
PARENT GUARDIAN INFORMATION
Name of Parent/Guardian*
First
Email*
Phone
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Select Today's Date*
MM slash DD slash YYYY
By checking "Create Account," your form information and data will be saved. You may log into your account at anytime to revise and edit submitted forms. You will also be able to upload documents, i.e. medical clearance, photo ID and other data to your account.
Create Account
By checking "Create Account," your form information and data will be saved. You may log into your account at anytime to revise and edit submitted forms. You will also be able to upload documents, i.e. medical clearance, photo ID and other data to your account.
MINOR INFORMATION
Name of Minor (Participant)*
First
Birthdate (Minor)*
MM slash DD slash YYYY
Age as of July 31 (Minor)*
Check if applicable
Add another minor participant.
Name of Minor (2) (Participant 2)
First
Birthdate (Minor 2)
MM slash DD slash YYYY
Age as of July 31 (Minor 2)
Phone (Minor)
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of School (Fall)
Grade in Fall
School Phone
Medical Insurance
Name of Insurance Carrier
Policy Number

Association: Berkeley Jr Jackets
Upload Photo (Minor)
Max. file size: 128 MB.
I acknowledge that I am fully aware of the potential dangers of participation in any sport and I fully understand that participation in football, cheerleading, dance and/or step may result in SERIOUS INJURIES, PARALYSIS, PERMANANET DISABILITY AND/OR DEATH. Furthermore, I fully acknowledge and understand that protective equipment does not prevent all participant injuries. I, the parent/guardian of the above-named participant, do hereby give my approval for my child/ward to participate, and further assert that I have verified with my child/wards physician, and in my opinion, my child/ward is physically fit and can participate without limitation in any and all Local, Regional, National, League/Conference, Association and team/squad activities, including transportation to and from the activities by a licensed driver.
Parent Guardian Consent*
I agree
I am of the opinion that my son/daughter/ward is scholastically fit and would benefit by participation in this program. I agree to submit a copy of my son/daughter/ ward's last completed grade, end of year/last complete report card or a written statement of scholastic fitness from the school administration.
Parent Guardian Consent*
I agree
We acknowledge, AND WE understand the risks involved in my CHILD/WARD, my playing FOOTBALL, which is a collision sport; the NOCSAE committee has adopted the following warning to be read by, and signed by, both the parent/guardian and participant. DO NOT USE THIS HELMET TO BUTT, RAM OR SPEAR AN OPPOSING PLAYER, THIS IS IN VIOLATION OF FOOTBALL RULES AND CAN RESULT IN SEVERE HEAD, BRAIN OR NECK INJURY, PARALYSIS OR DEATH AND POSSIBLE INJURY TO YOUR OPPONENT, THERE IS A RISK THAT THESE INJURIES MAY ALSO OCCUR AS A RESULT OF AN ACCIDENTAL CONTACT WITHOUT INTENT TO BUTT, RAM OR SPEAR, NO HELMET CAN PREVENT ALL SUCH INJURIES.
Parent Guardian Consent*
I agree
Minor Consent
I agree
I assume full responsibility for any and all equipment/uniforms loaned to my child/ward and I agree to promptly return, upon request, the uniform and other equipment in as good condition as when received except for normal wear and tear. If I fail to adhere to this policy, I will be responsible for and promptly pay the replacement cost of such equipment.
Parent Guardian Consent*
I agree
The Ideology Of Youth Sports Including This Program Is To Promote Good Understanding And Fundamental Knowledge Of The Sport. It Is Also Critical That Good Sportsmanship Including The Ability To Always Conduct Oneself In An Appropriate Manner Of Positive Accord Both On And Off The Field. It Is Understood That Any Incident Considered Detrimental To The Pursuit Of This Ideology Will Not Be Tolerated. It Will Be Addressed In Accordance With The Statutes Of The Association, Conference, Current National Affiliation, State and Local Laws, And May Result In Dismissal From The Program And The Inability To Participate In Any Future Related Activities Of The Association. This Code Of Conduct Applies To All Involved With The Program Including But Not Limited To, The Football Players, Cheerleaders, Spirit Participants, Parents And Guardians.
Parent Guardian Consent*
I agree
Parent/Guardian Signature*
Minor Initial*
Please sign Minor's intials here.

WAIVER AND RELEASE OF LIABILITY
Association Name: Berkeley Jr Jackets
By signing below, I fully understand that: 1) The risk of injury to my child/ward, myself, from the activities involved in these programs is significant, including the potential for permanent disability, paralysis 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, 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 child/ward, 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 concern in my child/wards', readiness or, hazard during my presence or participation, and/or in the program itself, I will remove my, child/ward, from participation and bring such to the attention of the nearest official immediately; and,
4) I, for myself, my spouse, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS American Youth Football, Inc.(AYF), the local organization, their respective officers, directors, officials, volunteers, agents, and/or employees, other participants, sponsoring agencies, tournament host, 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, incident to my child/wards', involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, TO THE FULLEST EXTENT PERMITTED BY LAW.
5) I, for myself, my spouse, 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 Releasees from any and all liabilities incident to my child/ward's involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.
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 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.
Yes, I agree and consent to terms.
UNDERSTANDING OF RISK (MINOR)*
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.
Yes, I agree and consent to terms.

Emergency Medical Treatment, Consent and Information

Association Name: Berkeley Jr Jackets
The following information will be used in the event that a parent / legal guardian is not available. The purpose of this information is to provide a quick reference for medical personnel should the need arise. Please fill out this form completely. If a particular question is not applicable write "none", n/a, or other appropriate comment otherwise none will be assumed. If additional space is needed, please use the back of this form. All information disclosed here will be treated as confidential. It will be the responsibility of the parent/legal guardian to notify the participants coach and league/event officials if any information needs to be added, deleted, changed, or updated in any way.
ATHLETE INFORMATION
Name of Minor*
First
Nick Name
First
Phone (Minor)
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

PARENT OR GUARDIAN INFORMATION
Father's Name
First
Home Phone
Daytime Phone
Email

Father's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mother's Name
First
Home Phone
Daytime Phone
Email

Mother's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Guardian Name
First
Home Phone
Daytime Phone
Email

Guardian's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

FAMILY MEDICAL INSURANCE
Name of Insurance Carrier

Group

Group Number

Policy Holder Name

Family Physician's Name

Physician's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Physician Phone
Physician Email

EMERGENCY MEDICAL INFORMATION
Preferred Hospital(s)

Emergency Contact

Relationship

Phone
Please list any medical conditions (allergies, asthma, etc.) And medications being taken by the participant named above. Please list any other information you may deem relevant, and helpful to emergency medical personnel: (please note if no information is given and the words "none" or "n/a" is not filled in then, "none" will be assumed.
Allergies
Medical Conditions
Other
Upload Signed Medical Clearance Form
Max. file size: 128 MB.
Form must be dated after January 1st of the Current Season
Confirm the following*
By signing below, I hereby grant permission for my child/ward to participate in any and all, Young Lives Matter Foundation and, American Youth Football, Inc. program(s) event(s), including but not limited to, athletic, social and/or fundraising activities. I further consent to the administration of any and all medical treatment necessary to stabilize and or treat any medical condition or medical emergency to which my child/ward is afflicted. I understand that this authorization is given prior to the need for medical care, but given in advance to avoid any unnecessary delay in emergency treatment which the attendant and/or medical professional may deem advisable in the exercise of their best judgment.

Select Payment Option

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PLEASE READ: After your form is submitted and payment is complete, you will receive an email with the registration confirmation and your account username and password. You may log into your account at anytime should any form changes, revisions or updates be necessary. If you were unable to complete your form, you may do so through your account at any time. Important! You should receive your email confirmation and account info within 10 minutes of form submission. Please be sure to check your junk mail. If you do not receive the notification, please contact us at 510-269-7572 or email us at info@younglivesmatter.com.
REGISTRATION PAYMENT
Association: Berkeley Jr Jackets Merchant name as appears on statement: Young Lives Matter Foundation
Registration Fee Quantity*
Price: $50.00
Total
$0.00
After purchase, you will receive email confirmation within 10 minutes. If you do not see confirmation email, please check junk mail folder.

Form 1

AMERICAN YOUTH FOOTBALL FORM (3)

Step 1 of 6

PARENT GUARDIAN INFORMATION

MINOR INFORMATION

IMAGE RELEASE – MINOR

WAIVER AND RELEASE OF LIABILITY

Emergency Medical Treatment, Consent and Information

ATHLETE INFORMATION

PARENT OR GUARDIAN INFORMATION

FAMILY MEDICAL INSURANCE

EMERGENCY MEDICAL INFORMATION

REGISTRATION PAYMENT

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Hours

Mon - Fri 7:30 am - 7:30 pm
Sat - Sun 7:30 am - 2:00 pm

AMERICAN YOUTH FOOTBALL FORM (3)

Step 1 of 6

PARENT GUARDIAN INFORMATION

MINOR INFORMATION

IMAGE RELEASE – MINOR

WAIVER AND RELEASE OF LIABILITY

Emergency Medical Treatment, Consent and Information

ATHLETE INFORMATION

PARENT OR GUARDIAN INFORMATION

FAMILY MEDICAL INSURANCE

EMERGENCY MEDICAL INFORMATION

REGISTRATION PAYMENT

About

We are a full-service digital marketing firm specializing in results-based online marketing, designed to maximize lead generation for your business. 44050 Ashburn Shopping Plaza, Suite 195-636 Ashburn, VA 20147 Phone: 703-520-5028 Email: info@SEOAshburn.com

Locations

Ashburn VALeesburg VASterling VABroadlands VALansdowne VANorthern VirginiaNorthern VALoudoun County VAHerndon VAReston VAFairfax County VAPrince William County VAArlington County VAMontgomery County MDWashington DC

Industries

Home Services Contractor Dental MedSpa Medical Financial Healthcare Insurance IT Law Firm Lifestyle Real Estate Plumbing Non-Profit

Services

Search Engine OptimizationSearch Engine MarketingContent MarketingDigital MarketingOnline MarketingEmail MarketingSocial Media MarketingWebsite DesignWordpress DevelopmentOnline Reputation ManagementChatbot DevelopmentSEO

Hours

Mon - Fri 7:30 am - 7:30 pmSat - Sun 7:30 am - 2:00 pm

We are a full-service digital marketing firm specializing in results-based online marketing, designed to maximize lead generation for your business.

44050 Ashburn Shopping Plaza, Suite 195-636 Ashburn, VA 20147

Phone: 703-520-5028

Email: info@SEOAshburn.com

Ashburn VA
Leesburg VA
Sterling VA
Broadlands VA
Lansdowne VA
Northern Virginia
Northern VA
Loudoun County VA
Herndon VA
Reston VA
Fairfax County VA
Prince William County VA
Arlington County VA
Montgomery County MD
Washington DC

Home Services
Contractor
Dental
MedSpa
Medical
Financial
Healthcare
Insurance
IT
Law Firm
Lifestyle
Real Estate
Plumbing
Non-Profit

Search Engine Optimization
Search Engine Marketing
Content Marketing
Digital Marketing
Online Marketing
Email Marketing
Social Media Marketing
Website Design
Wordpress Development
Online Reputation Management
Chatbot Development
SEO

Mon - Fri 7:30 am - 7:30 pm
Sat - Sun 7:30 am - 2:00 pm