1. Official Use Only
BMF&C 7 on 7 FOOTBALL
Jersey # ________
2014 Registration
Player’s Name: _______________________________________
Phone: ___________________________
Address: ___________________________________________
Cell Phone: _______________________
Email Address: ______________________________________
Date of Birth: _____________________
School: ____________________ Present Grade: _________
Birth Certificate: Yes or No _________
(ONLY for new members)
officer initials
Age as of 6/14/2014: __________
Fathers Name: ____________________________
Mothers Name: _____________________________
With whom does the child reside? _____________________________
Name of Insurance Carrier: ______________________________ Policy #: _________________________
I/We certify that the above information is correct. I/We give permission for my/our child to participate in the Bloomsburg
Midget Football Program. I/We understand that Medical Insurance covering my/our child is required and is my/our
responsibility. I/We, the parents/guardians of the above named participant of Bloomsburg Midget Football League, Inc.,
hereby give my/our approval to participate in any and all Bloomsburg Midget Football activities, including transportation
to/from activities. I/We understand that participation in midget football may release, absolve, indemnify and agree to hold
harmless Bloomsburg Midget Football League, Inc., the organizers, sponsors, coaches, other participants and persons
transporting my/our child to/from activities for any claim arising out of any injury to my/our child whether the result of
negligence or any other cause. A completed emergency form will be required for all players once the practice season
begins.
$45.00 (including shirt and shorts) for the summer session
Signature of Parent/Guardian: _____________________________________
JERSEY SIZE:
Date: _______________
SHORT SIZE:
Youth
S
M
L
XL
Youth:
S
M
L
XL
Adult
S
M
L
XL
Adult:
S
M
L
XL
Officer Use Only
Date: _________________ Registration fee pd: ________ Check #: ________ Cash: ________ Officer initials: ________