Prince Edward Youth Football and Cheerleading

2. 2022 Prince Edward Youth Football & Cheerleading Form
4. Participant Full Name*

   AS IT APPEARS ON BIRTH CERTIFICATE

6. Birth Date*
   Birth Date
7. Age*
8. Gender*

   1. Male
   2. Female
10. Parent/Guardian Name*
11. Primary Phone Number*
13. Email Address
14. Alternative Phone Number*

    Please include a secondary number in case the first cannot be reached.

16. Address
18. City
19. State
20. Zip Code
22. Physician Name*
23. Physician Number*
25. Sport:*
    -- Select One --Flag Football (Ages 5 – 7)Minor Football (Ages 8-9)Junior Varsity Football (Ages 10-11)Varsity Football (Ages 12-13)Flag Cheerleading (Ages 5 – 7)Minor Cheerleading (Ages 8-9)Junior Varsity Cheerleading (Ages 10-11Varsity Cheerleading (Ages 12-13)

    Please complete one form per sport and per player

27. Uniform Size*
    -- Select One --Youth X-SmallYouth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-Large
29. *****Football and Cheerleading: All Parents or Guardians must submit with this registration form, a copy of the participant’s birth certificate and a physical examination form. Eligibility is based on the child’s age as of September 1st for the current year.*****
31. FEES

    $55.00 per first child for: 

    Youth Football & Cheerleading ($10 late fee per child)

    $50.00 per additional child for:                     

    Youth Football & Cheerleading

    **All Fees must be paid in full before participation. Refunds are subject to a $20.00 Administrative fee. No refunds will be issued after July 22, 2022**

33. Parent/Guardian Participation*

    I/We are willing to participate in the following activities for the Farmville Recreation Department’s Youth Football & Cheerleading program.

    COACHES: Please submit this registration and the NAYS certification to the Recreation Department. (twoodson@farmvilleva.com)

    https://www.nays.org/

    1. Coach
    2. Fund Raise
    3. Concessions
    4. Chain Crew
    5. Gate Attendant
    6. Assist Officials
    7. None
35. Consent/Waiver Agreement

    I/We consent to our child participating in the Farmville Recreation Department Programs. In participating in Recreation Programs, sponsored by The Town of Farmville, I hereby acknowledge that I/We understand that there are risks of accidents resulting in bodily harm arising out of those activities. I/We  understand that Recreation activities are planned with the safety of the participants in mind. In case of emergency, accident or illness, if I/We am not  present I/We hereby give our permission for the coach or representative of the Recreation Department to obtain any required medical attention my child may need. I/We will notify the coach of any physical limitations (allergies, hearing, sight, etc) or other additional information they need to know about  my/our child. I/We further acknowledge that my child has the physical capacity reasonably necessary to engage in Recreation activity for which I have enrolled. I/We agree to be the party responsible for all medical expenses which are incurred in my behalf. It is understood and agreed that the Town, it’s Mayor, Town Council, Boards, employees, volunteers and agents shall be held harmless against all claims, damages, loss or expenses including attorney’s fees arising out of or resulting from participation in recreation programs. I/We agree any pictures taken may be used for future promotions for the Town of Farmville.

37. ** I have read the above waiver and understand the contents***

    Type Parent/Guardian name

39. Date of Agreement to Consent/Waiver Agreement*
    Date of Agreement to Consent/Waiver Agreement
43. Birth Certificate Submission*

    Please upload an image or pdf scan of the participants birth certificate here. This is required for both youth football and cheerleading.

    Please be sure that the attached document is not blurry or distorted.

44. Physical Examination Form*

    Please upload an image or pdf scan of the participants physical examination form here. This is required for both youth football and cheerleading.

    Please be sure that the attached document is not blurry or distorted.

46. For more information contact the Farmville Recreation Department at (434) 391-1125, or e-mail: twoodson@farmvilleva.com.

     

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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

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