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Coaching Application

CORI Form

Flag Football Fees

Division

Grade in

9/2011

Early Fee

4/1/11 - 4/30/11

Regular Fee

5/1/11 - 5/31/11

Late Fee

After 6/1/11

Instructional

 K, 1

$40

$45

$80

Freshman

2, 3

$40

$45

$80

Junior

4, 5

$55

$65

$100

Senior

6, 7, 8

$55

$65

$100

Family Max

$110

$140

$200

2011 Wachusett Youth Flag

Football League Registration

Participant:

Last Name                                                                      

First Name                                                   

MI               

Address                                                                          

Town                             

State                  

Zip              

Date of Birth        /          /            

Grade in fall ‘11            

Last year’s team / division                                                   

Parent/Guardian:

Last Name                                                                       

First Name                                                                        

Phone #:                                                                          

Email                                                                                 

Interested in sponsoring a team              YES o

Mail completed registration forms and payment to:    WYFFL, P.O.  Box 689, Holden, MA  01520

If you have questions, see our website at www.wachusettflagfootball.com

The following section must be completed for all Flag Football participants

Liability Release and Consent for Medical Treatment (MINOR)

I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the Wachusett Youth Flag    Football League, and its sponsors and coaches. I and the registrant  recognize the possibility of personal injury and damage to personal property associated with the flag football programs and activities (the “programs”). I herby release, discharge and/or otherwise indemnify the Wachusett Youth Flag Football League, its affiliated organizations and sponsors, their associated personnel, including the owners of the fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs

I herby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine. This care may be given under whatever conditions are  necessary to preserve life, limb, or well being of my dependent.

Please sign below as a Liability Release, Consent for Medical Treatment.

Parents Signature                                                                                                                                                         

Emergency Phone #                                                                                                                                                      

Primary Care Physician                                                                                                                                                  

Phone#                                                                                                                                                                       

Health Care Provider                                                                                                                                                     

Provider #                                                                                                                                                                   

Medical Conditions or Allergies                                                                                                                                        

This document is valid for 1 year from the date it was signed