This document contains a registration form for the Bloomsburg Midget Football & Cheerleading program. It requests information such as the cheerleader's name, address, phone number, date of birth, insurance information, and emergency contact. The parent or guardian must sign agreeing to terms such as allowing their child to participate, holding the program harmless, and returning equipment. There is a registration fee of $50 with discounts for multiple siblings, and late fees may apply for registrations after certain dates.
1. Official Use Only
BMF&C CHEERLEADING
Team__________
2014 Registration
Cheerleader’s Name: __________________________________
Phone: ___________________________
Address: ___________________________________________
Cell Phone: _______________________
Email Address: ______________________________________
School: ____________________ Present Grade: _________
Date of Birth: _____________________
Birth Certificate: Yes or No _________
(ONLY for new members)
officer initials
Age as of 11/1/2014: _________
Team on last year: A or B or C / Red or White / New Cheerleader
Do you have a sister/brother already on a team? _______
Fathers Name: ____________________________
If yes, what team? Red
or
White
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. I/We agree to return all equipment issued to my/our
child in as good condition as when I/We received it, except for normal wear and tear. If equipment is not returned on
the return date, I/We will be responsible for a late fee and/or any equipment items not returned. You could also forfeit
your right to participate in later years of midget football. A completed emergency form will be required for all players
once the practice season begins.
$50.00 Registration Fee with a multi-cheerleader discount (1st $50.00, 2nd $40.00, 3rd $40.00, etc.)
($10 late fee for those not registering on the scheduled dates
and any registrations after June 1 will incur a $25 late fee)
Signature of Parent/Guardian: _____________________________________
Date: _______________
Officer Use only
Date: ______ Registration fee pd: ______ Jersey fee pd: ______ Check #: ______ Cash: ______ Officer initials: ______