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2018 PRIDE OF IOWA YOUTH FOOTBALL LEAGUE

Please PRINT all Information-
                                                           
Player’s Name:                                                                                                            

Birthdate:                                                                                                                                 

Address:                                                                                                                                  

Phone Number:                                                                                                                       

List any allergies:                                                                                                                      

Doctor:                                                             Phone Number:                                  

Address:                                                                                                                                  

Person to Contact In Case of Emergency:

Name:                                                                          Phone # :                                            

Relationship to Child:                                                    Cell # :                                               

Insurance Information:

Insurance Co. Name:                                                                                                               

Subscriber Name:                                                                                                                    

Insurance Number:                                                                                                                  

 

I,                                                                                  , as parent/guardian of the above participant, certify that the above participant is both physically and mentally able to play in the Pride of Iowa Youth Football League and has health insurance and will have coverage through the duration of the Pride of Iowa Youth Football League Season.  I also hereby give my permission to the above named doctor and/or medical facility to treat the above named participant in case of injury.

 

Signature or Parent or Guardian:                                                                                              

Printed Name of Parent or Guardian:                                                                                        

Date: