Asthma_______ Diabetes_____ Heart Disease_____

Headaches_____ Seizures_____ Black Outs_______

Chest Pain_____

Specify Below:

Other Medical Issues:______________________________________________

Allergies/Injuries/Medication being taken______________________________

Program Information & Fees (Check One):

Atom Tackle $125__________ Peewee Tackle $150__________
Born 1999 -- 2001                         Born 1997 - 1998

Junior Bantam $210_________ Bantam $210________________
Born 1995 - 1996                         Born 1993 - 1994

A $35.00 administration fee will be charged to players who have not started playing regular season games & wish to withdraw from playing for the season. There is no refund available once a player has commenced playing regular season games.

Equipment Deposit: $175.00

The following equipment will be provided to each player:

Helmet/Mouth Guard/Shoulder Pads/Girdle/Safety pads/belt/practice pants/Game Uniform/Game socks.

Each player must provide a practice jersey & suitable approved footwear (cleats)

Your equipment deposit cheque must be presented before the equipment is handed

out & will be held until the end of the players season & until all the players equipment is returned in clean & appropriate condition.

Players who advance to provincial playoffs may incur additional costs to cover out of town trips.

ALL CHEQUES ARE TO BE MADE OUT TO:

VERNON & DISTRICT MINOR FOOTBALL ASSOCIATION (VDMFA)

CONSENT:

I, the Parent/Guardian of the above named minor hereby consent to his/her participation in any or all of the activities of the Vernon & District Minor Football Association & I acknowledge & fully understand & agree to assume all risks & hazards involved in & arising out of the acceptance of the above named minor''s application to be registered to participate in the association''s activities. I hereby waive, release, forgo & forever relinquish any & all the claims, demands, suits, actions or causes of employees, agents, volunteers & any person participating or assisting in the carrying out of the association''s objectives, arising out of or resulting from or incidental to the activities of the Association.

AND FURTHER I hereby agree to hold & save harmless Vernon & District Minor Football Association from any loss or damage & from any claims, demands, suits, actions, causes, causes of actions resulting from or arising out of or occasioned by the above named minor''s participation in any or all activities of the Association.

_________________________ _____________________________
Signature of Legal Guardian         Signature of Witness

_________________ _______________ _____________________________
Printed Name             Date                            Printed Name

VOLUNTEER INFORMATION

The VDMFA requires parent & family volunteer participation.

Each team will be required to provide the following volunteers for practices and/or
Games:

Please check the areas you would like to help with:

First Aid Attendant -- Level 1 or better ___________
(Games & practices)

Team Manager _______________ Team Sponsor _____________

Coach Helper ________________ Field Volunteers ___________
(Practices only)                             (Games only)

Game Commissioner __________ Fundraising Committee _____

Field Crew/Chain Gang _______ 50/50 Coordinator __________
(Games only)                                (Games only)

Final checklist:

~ Fill in all information on Pages 1, 2 & 3

~ Photocopy of Birth Certificate

~ Sign & Date Waiver/ Witness for Waiver

~ Enclose Registration Payment