Junior Football League
May 15-June 2 Prices
2&3 grade $50.00
4&5 grade $85.00
6 grade $95.00
Childs Information
Player Name:___________________________________________________________Grade:__________________
Birth Date:_________________________ Age:______________________ Weight:__________________________
Has your child participated in a CONTACT football program?
YES
NO
Parents Name(s): _______________________________________ Parent Birth Date:_________________________
Address:_______________________________________________________ Township:_______________________
Primary Phone:___________________________________ Alternate Phone:_________________________________
Email:_________________________________________________________________________________________
Uniform per GRADE:
2nd & 3rd Grades- Please circle a Shirt Size
Youth Small
Youth Medium
Youth Large
Adult Small
2nd & 3rd Grades-Please circle Athletic short size:
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Medium
Adult Large
Adult Large
4th& 5th Grades Please circle a Jersey Size (circle one size larger than regular t-shirt)
Youth Large
Adult Small
Adult Medium
Adult Large Adult X-Large
Adult XX-Large
6th Grade- Please circle a Jersey Size (circle one size larger than regular t-shirt)
Youth Large
Adult Small
Adult Medium
Adult Large Adult X-Large
Adult XX-Large
6th Grade-Please circle Athletic short size:
Youth Medium
Youth Large
Adult Small
Adult X-Large
Adult Medium
Adult Large
Adult XX-Large
Coaching
Would you be interested in Coaching?
Head Coaching
If interested in coaching MUST fill out a coaches form.
Assistant Coaching
Sponsorship
Are you or someone you know interested in sponsoring a JFL team? YES
Help when can
NO
Company Name:______________________________________________________________________________
Contact person:_________________________________ Contact Number:_______________________________
In case of Emergency Contacts
Name
Phone
Relationship to Player
Name
Phone
Relationship to Player
Please list any allergies/medical problems, including requiring maintenance medication
(i.e. Diabetic, Asthma, Seizures). The purpose of the below listed information is to ensure that medical personnel
have details of any medical problem which may interfere with or alter treatment.
Medical Diagnosis
_______________
_______________
_______________
_______________
_______________
_______________
Medication
__________
__________
__________
__________
__________
__________
Dosage
________
________
________
________
________
________
Frequency of Dosage
_________________
_________________
_________________
_________________
_________________
_________________
Parent or Guardian Authorization
In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by
Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).
I, _______________________________________________ (parent, guardian) hereby take and accept full
responsibility for ____________________________ (my child, ward) in the undertaking of JFL. I hereby affirm that
________________________________________ (child/ward) is physically able to participate in the sport/activity
described.
Authorized Parent/Guardian Name Printed:_________________________________ Date:________________
Authorized Parent/Guardian Signature:__________________________________________________________
l injuries a player might receive while participating in JFL.
***Players will be weighed when they pick up their equipment **
ATTESTATION AND RELEASE - JUNIOR FOOTBALL LEAGUE
PLEASE READ AND, IF ACCEPTED, SIGN BELOW
(must be signed before participation in the athletic activity).
The undersigned, ____________________________________, parent/guardian of
________________ (the “ Participant” ) hereby and forever discharge and release the City of
Columbia City, its employees, officers, elected officials, Park Board members and employees,
coaches, staff, representatives, agents, its successors and assigns, from all debts, claims,
demands, damages, actions and causes of action whatsoever, which the Participant, the
Participant’s heirs, parents, family, “ friends of” , executors, administrators, or assigns may now
have or may hereafter have, as a result of the Participant’s participation in the Columbia City
Park’s Department Junior Football League during the current year.
To the extent allowed by law, I, on behalf of and for the Participant, hereby voluntarily waive any
and all claims, both present and future, arising from his/her participation in the Columbia City
Junior Football League, including but not limited to negligence, property damage, personal injury,
and wrongful death. However, nothing herein will be deemed to be a waiver of the City's
responsibility for the negligence or willful acts of the City's agents and employees. Further, the
Participant, or those acting on behalf of the Participant, will indemnify, defend and hold the City
harmless from all costs, expenses, liability, claims, actions, causes of action, or damages sustained
by reason of any occurrence causing injury or death to any person or damage to property due
directly or indirectly to acts or omissions of the Participant.
I, on behalf of and for the Participant, attest and verify that I have full knowledge of the risks
involved in this athletic activity, including, but in no way by limitation, those involving concussions
and neck injuries, and that the Participant is physically fit to participate in this athletic activity. By
having read this waiver, understanding the terms and attesting to the conditions and releases of
this waiver, and signing same voluntarily, I understand in consideration of allowing the
Participant’s participation in the athletic activity, the Participant, for him/herself and anyone
entitled to act on the Participant’s behalf, waive and release any sponsors, land owners, athletic
activity coordinators, coaches, staff, officials, employees, volunteers, the City of Columbia City,
and/or any others associated with this athletic activity from any claims of any kind arising out of
participation in
this athletic activity.
Parent’s/Legal Guardian’s signature __________________________________________________
on behalf of ____________________________________, the “ Participant ” Date: ______________