Youth Athlete Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone # *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Doctor Phone Number *

(###)

###

####

Photo Permission *

I permit my child's photo to be displayed on Vienna Wildcats Facebook page.

Yes

No

Waiver & Permission *

I, the undersigned parent/guardian of the above named child, give my permission for my child to participate in the Vienna Youth Football Inc. I have been advised and understand that there is a risk of injury associated with participation in the sport and do hereby assume that risk. I further understand by signing this document, I agree not to hold any coach, assistant coach, commissioner, any officer of Vienna Youth Football Inc, or any other party or individual liable for any injury which may incurred by my child during participation in this sport. I further understand that I am liable for the return of the uniform and equipment that is assigned to my child for the season. I understand that if I do not return ALL uniforms and equipment that is issued to my child at the end of the season that I will be responsible for the cost of replacing this equipment, which may be up to approximately $500.00.

Waiver Signing Parent /Guardian *

First Name

Last Name