Rooted Bible Fellowship Church

Kingdom Football Registration Form

YOUTH INFORMATION

page 1 of 2

Name *


First Name	Last Name

Date of Birth *

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Age (Age of youth at start of season. Must not exceed age requirement) *

Address *


Address

Address Line 2

City	State	Zip Code

Home Phone *

Phone Number

Secondary Phone

Phone Number

Cell Phone

Phone Number

Email Address

Current School *

Grade *

Tee Shirt Size Youth *

Select from list

PARENT / GUARDIAN INFORMATION

page 2 of 2

Primary Parent/Guardian *


First Name	Last Name

Relationship to Youth *

Current Address *


Address

Address Line 2

City	State	Zip Code

Home Phone *

Phone Number

Secondary Number

Phone Number

Cell Phone

Phone Number

Email Address

Secondary Parent/Guardian


First Name	Last Name

Relationship to Youth

Current Address


Address

Address Line 2

City	State	Zip Code

Home Phone

Phone Number

Secondary Number

Phone Number

Cell Phone

Phone Number

Email Address

Emergency Contact other than Parent/Guardian *


First Name	Last Name

Phone *

Phone Number

Physician's Name


First Name	Last Name

Phone

Phone Number

BY SIGNING THIS FORM: The parent/guardian assumes all risks associated with participation in the program. RBF Church and ministries will assume no liability for injury or damages arising from participation in this youth program. Due to the strenuous nature of flag football a signed physical by a licensed physician is required to establish fitness of youth. It is the parent/guardian responsibility to disclose any health risk the youth may have. The parent/guardian consents to emergency treatment on behalf of the minor. By signing this form you are also consenting to the use of photographs and/or video tapes for training and promotional purposes. It is the responsibility of the parent/guardian to pick up or make arrangements for your youth to be picked up in a timely manner. NO YOUTH SHALL BE DROPPED OFF?LEFT ALONE BEFORE APPROPRIATE STAFF MEMBERS ARE IN PLACE TO RECEIVE CHILDREN.

Parent/Guardian Signature *

Date *

Click in box to select date

* required