Applicant Information
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Most Recent Organization:

Parent/Guardian Information
Relationship:
Mother Other
Relationship:
Mother Other
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Emergency Contact Information
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In the event of accident or other emergency, when a parent or guardian is unavailable, I hereby authorize a representative of the Delta Junior Saints to make such arrangements, as he/she considers necessary for my child to receive medical or hospital care and transportation. Under such circumstances, I further authorize the physician named below to provide care and treatment for my child as he/she considers necessary. In the event the said physician is not available at the time, I authorize such care and treatment to be performed by andy licensed physician or surgeon. The undersigned hereby agrees to bear all costs incurred as a result of the foregoing.
Please make a selection. April 26, 2011

Medical Information

Physician's Phone
Dentist Phone
Health Insurance Carrier:
 Insurance/Medical Record #
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Please Check Those Items That Apply To Your Child
Health Problem Or Physical Condition Which Limits Participation In Youth Sports?
No
Allergic To Medication?
No

Idemnification
  1. I/We have read, understand and agree, as parent(s)/guardian(s) of the above named child applicant to abide by the rules of the parent and player's Code of Conduct and assume the absolute financial obligation for my/our child to participate in this youth program.
  2. The above child applicant understands and agrees to abide by the Player Code of Conduct.
  3. The parent(s)/guardian(s) of the above named child applicant, do hereby give approval for participation in the Delta Jr Saints Football and Cheer (DJS) activities for the current season. I/We assume all risks and hazards of participation for any claims arising out of injury to the above named child applicant, including, but not limited to, transportation to and from such activities. I/We hereby waive, release, absolve, indemnify and agree to hold harmless, DJS, NCSA, the league, local team, organizers, managers, coaches, supervisors, participants, person providing transportation and any organization this youth football program may be affiliated with.
  4. In executing the foregoing release, I/we acknowledge that I/we understand that our personal medical/dental insurance will remain the primary carrier, and that insurance offered through this program is secondary in nature and is subject to an annual deductible by the carrier. It is understood that any claim for injury arising out of my/our child's participation be reported to the designated association official within 30 days of the date of injury. It is also understood that the proof of loss must be completed in full and filed within 60 days of receipt by DJS. All monies I/we have paid to the team do not constitute payment of insurance coverage. I/We attest that I/we have read and understand the terms of this contract and any disclosure information required.
  5. I/We understand that if player/cheerleader has not had their physical examination they will not be allowed to participate in andy DJS activities. I/We hereby grant authority to a qualified physician to administer such medical treatment, as said physician deems necessary under emergency circumstances.
  6. I/We have read and understand fully the provisions of this consent/release authorization, and I/we have voluntarily signed it.

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