Form 1 AMERICAN YOUTH FOOTBALL FORM (3) AMERICAN YOUTH FOOTBALL REGISTRATION Step 1 of 6 16% Minor Name (Participant)* First Last Parent/Guardian Name (Participant)* First Last Association: Berkeley Jr Jackets Already have an account with us? Log onto berkeleyjrjackets.org/wp-admin and enter username and password. If you did not receive email with account login info, please check junk mail.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 INFORMATIONName of Parent/Guardian* First Email* PhoneHome 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 AccountBy 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 INFORMATIONName 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name of School (Fall) Grade in Fall School PhoneMedical InsuranceYesNoName of Insurance Carrier Policy Number Association: Berkeley Jr JacketsUpload 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 agreeI 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 agreeWe 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 agreeMinor Consent I agreeI 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 agreeThe 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 agreeParent/Guardian Signature*Minor Initial*Please sign Minor's intials here. Association: Berkeley Jr JacketsIMAGE RELEASE – MINORAssociation Name: Berkeley Jr JacketsBy signing below, I express my full understanding that American Youth Football Inc., is hereby granted the unrestricted right and permission, free from approval or review, to copyright and/or use my child's/ward's likeness in all media now or hereafter known, including but not limited to, pictures and videos of my child which he/she may be included intact or in part for promotion or other commercial use. WAIVER AND RELEASE OF LIABILITYAssociation Name: Berkeley Jr JacketsBy 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 JacketsThe 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 INFORMATIONName 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 INFORMATIONFather's Name First Home PhoneDaytime PhoneEmail Father's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mother's Name First Home PhoneDaytime PhoneEmail Mother's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Guardian Name First Home PhoneDaytime PhoneEmail Guardian's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code FAMILY MEDICAL INSURANCEName 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 PhonePhysician Email EMERGENCY MEDICAL INFORMATIONPreferred Hospital(s) Emergency Contact Relationship PhonePlease 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.AllergiesMedical ConditionsOtherUpload Signed Medical Clearance FormMax. file size: 128 MB.Form must be dated after January 1st of the Current SeasonConfirm the following*I have upload a valid Medical Clearance FormI will submit Medical Clearance Form at a later timeBy 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 Pay Now and Submit Submit Now and Pay Later 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 [email protected] REGISTRATION PAYMENTAssociation: Berkeley Jr Jackets Merchant name as appears on statement: Young Lives Matter FoundationRegistration Fee* Price: $50.00 Quantity 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.