Payment _____________________

Cash or Check #
Receipt # ____________________

Birth Certificate Recd _________
Sylvania Peewee Athletics FOOTBALL
PLAYER INFORMATION AND MEDICAL RELEASE FORM

Player's Name_________________________________________Date of Birth____________ _Age as of today________
Address______________________________________________City________________State______Zip________
Enter cell # for text messages regarding practices and team info. Do you wish to receive texts? ____________________
EMERGENCY INFORMATION
Father/Guardian Name_______________________ Home # (____) __________Work # (____) _________Cell # (___) __________
Mother/Guardian Name ______________________Home # (____) __________ Work # (____) _________Cell # (___) __________
In an emergency when parents cannot be reached, please contact:
Name ____________________________Home # (____) ______________ Work # (____) ___________Cell # (___) _____________
Name ____________________________Home # (____) ______________ Work # (____) ___________Cell # (___) _____________
Allergies __________________________________Medications ____________________________________________
Other medical conditions ___________________________________________________________________________
Injuries in the past 12 months _______________________________________________________________________
Player's Primary Physician________________________________Telephone Numbers (____) ____________________
Players Orthopedic Physician_____________________________Telephone Numbers (____) _____________________
Medical and/or Hospital Insurance Company ________________________________ Phone (____) ________________
Policy Holder______________________________ Policy # _________________________Group # _____________
PARENTS APPROVAL AND MEDICAL RELEASE
Recognizing the possibility of physical injury associated with football and in consideration for the Peewee Athletic Organization and its
affiliates accepting the registrant for its football programs, practices and activities, I hereby release, discharge and/or otherwise indemnify the
Peewee Athletic Organization, DeKalb County Board of Education, Sylvania High School, Town of Sylvania, Sylvania Park Board, Council
members, Sylvania Peewee Athletic Coaches, officers, any officials or members of the above mentioned, any affiliated organizations and
sponsors, their employees and associated personnel , including the owners of fields and facilities utilized for the Programs against any claim by
or on behalf of the registrant as a result of the registrant's participation in the Programs and/or being transported to or f rom the same, which
transportation I hereby authorize.
I certify that there is no medical reason or physical incapacity that registrant cannot actively participate in program. Furthermore, in the
event that I cannot be reached, I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide registrant with
medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of such assistance and/or treatment.
I understand that I am responsible for any equipment that my child is given, and I will return the equipment at the end of the season.
Any equipment that I do not return, I will have to reimburse the Sylvania Peewee Athletic Association.
I understand the code of conduct for participants and parents as outlined in the by-laws, and pledge to ensure my child understands
the code of conduct and will further uphold parental code of conduct and accept consequences for failing to uphold said code.



_______________
(Parents Printed name) (Parents Signature) (Date)

Sworn to and subscribed before me this day of , 20__

________________________________________ My commission expires
Notary
Record used for Identification & # _______________________________________