Player Registration
Fall 2016 Youth Season
Name_______________________________________________________________________________
Street Address ______________________________________________________________________
City/State/Zip________________________________________________________________________
Phone Number_______________________________________________________________________
Birthday (MM-DD-YYYY) __________________________ Current Age/Grade: ___________________
Email Address_______________________________________________________________________
2015 Team/Coach (if applicable) ________________________________________________________
Other sibling(s) playing________________________________________________________________
Shirt Size (circle one):
Youth Sizes
S (6-8)
M (10-12)
L (14-16)
XL (18-20)
Adult S
Adult M
Adult L
Adult XL
Pay with Cash or Check made payable to NorthRoad Community Church for $100.00
PERMISSION TO PARTICIPATE
I, the parent/guardian of the registrant listed above, expressly acknowledge and agree: (1) the game of
flag football is a contact sport which involves a risk of bodily injury to each participant; (2) to disclose any
physical and/or mental condition or ailment of the registrant listed above, which may in any way increase
the risk of injury to either the registrant or to other participants; (3) NorthRoad I.M.P.A.C.T. Sports,
reserves the right to prevent registrant from participation if he/she poses a threat of injury to either
himself/herself or to others. In consideration for the registrant being accepted as a participant in the
program, I hereby release, waive, discharge, covenant not to sue, hold harmless and agree to indemnify
NorthRoad I.M.P.A.C.T. Sports and all persons, officers, coaches and officials, including the owners of
fields and facilities used for the program, from any and all liability as a result of any injuries, hurt or
damages sustained by registrant as a result of his/her participation in the program and/or being
transported to or from the same. I, the undersigned, have read and voluntarily sign the release and waiver
of liability and indemnity agreement and further agree that no oral representations, statements or
inducements apart from the foregoing written agreement have been made and further verify that the
information on the registration form is accurate and complete.
PRINT PARTICIPANT NAME (print legibly) ________________________________Date____________
PARENT/GUARDIAN SIGNATURE _______________________________________Date____________
(If the participant is under 18 years old)