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Pinnacle Youth Football
PO Box 102
Menan, ID 83434
2015 Spring Football Registration Fee $50 or $105.00
Last Name:________________ First Name:____________DOB____/___/______
Street Address:____________________
Home Phone:(____)_____-_______
School:_______________________ Grade: _____ Age:_____ Weight: ______
Coach: ____________________
Years Played: _______
Parent/Guardian Emergency Contact Information
Parent/Guardian #1 Last Name: __________________ First Name: __________
Work Phone: (___) ____-______
Cell Phone (___) ____-_____
Email Address: ______________________________
Parent/Guardian #2 Last Name: __________________ First Name: __________
Work Phone: (___) ____-______
Cell Phone (___) ____-_____
Email Address: ______________________________
Physician/Family Doctor: _______________________ Phone: (___)____-_____
Insurance Carrier: ___________________
Policy #: _____________________
Parent/Guardian Permission
No Refunds. Equipment will be issued when full registration payment is received. Players will not be allowed to
participate in Pinnacle Youth Football if payment is not received in full. Equipment rented is property of each local
school and/or youth football program and must be returned at the end of the season. The cost of replacing lost or
damaged equipment will be borne by the participant and/or their guardians.
Medical Authorization – Grant of Consent. I hereby certify that my child is in good health and may participate in
all activities. In case of emergency I give my permission for my child to be given emergency treatment at any
responsible hospital.
Liability Waiver. As the parent (or legal guardian) of the above named minor, I grant permission for the minor to
participate in all activities of Pinnacle Youth Football. I assume all risks and hazards incidental to tackle football,
including practices, games and transportation to and from all football related activities, and do hereby release and
waive all claims against Pinnacle Youth Football, its sponsors, volunteers and game officials.
Name: _______________________________ Date: _____/____/______
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