Football New Brunswick

U18 Registration Form

Player information:

First name

Last name

Street address

City / Town

Prov.

Postal code

Date of birth

Medicare #

Height

Weight

(Day-Month-Year)

Position(s)

Last team played for

Head coach of last team

Home phone

Cell phone

Preferred email

Emergency contact

Parent / Guardian  information:

Mothers name

Home phone

Cell phone

Preferred email

Fathers name

Home phone

Cell phone

Preferred email

Does your child have a medical condition / require medication that the coach should be aware of?

Yes     No

If Yes, please provide details

For team use only

Drug Education and Doping Control Policy

Completed

Confirmation of Date of Birth

Completed

Registration Fee

Paid

Waiver

I / we, (parents / guardian name(s)) ________________________________, wish to register our child, _______________________________, to participate in the U18 program which is being offered by Football New Brunswick.:

In consideration for the opportunity to have my child participate in the above program and on payment of the registration fee of $100, I / we agree that:  

1.  I / we and our child will be bound by, and will adhere to, the rules and standards of conduct prescribed for the above program by Football New Brunswick from time to time;

2.  I / we hereby release Football New Brunswick, its officers, directors, employees, volunteers and agents from all liability, claims, causes of actions of any kind whatsoever, in respect of damages I / (my child) may suffer as a consequence of my child sustaining personal injury, death or property damage or loss while participating in programs and activities of the Football New Brunswick

3. I / we do hereby agree to indemnify and hold harmless Football New Brunswick, its officers, directors, employees, volunteers and agents from any and all claims, demands, causes of actions of any kind whatsoever, including those involving negligence on the part of Football New Brunswick and/or any of its officers, directors, employees volunteers and/or agents that may be made or initiated by, or on behalf of my child, arising out of or connected with my said child’s preparation for or participation in any of the Football New Brunswick programs of activities.

4. Finally, I/we hereby authorize Football New Brunswick, its officers, directors, employees, volunteers and/or agents to collect personal information regarding my child and to make use of that information in circumstances that Football New Brunswick deems, in its discretion, to be appropriate.  I/we also understand and agree that photographs and/or video recordings of our child may be taken during Football New Brunswick events, and I/we authorize Football New Brunswick to publish any such photographs and/or video recordings.

DATED at (city / town) ____________________, New Brunswick on  (date) ______________, 2011.

__________________________                                       _____________________________

Witness                                                                                Parent or Guardian signature

                                      _____________________________

                                                                                                 Football New Brunswick