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Binns Bengals Youth Football, Inc by pr3GG4


									                                                          Binns Bengals, Inc.

                                                          Season Year: 2010

                             Football                       Cheerleading                   Division: Micro

Youth Name:             Date of Birth:


Home Phone:              Cell Phone:            Work Phone:

Email Address:

I/We, the parent(s) and/or legal guardian(s) of the above named youth, do hereby consent and agree that the above named youth may
be an active participant in the activities held by Binns Bengals, Inc. including, but not limited to, the annual Meet & Greet, picture
day, all pre-season, regular season, and post-season games, and weekly practices. I/We, do hereby release and forever hold harmless
Binns Bengals, Inc., its sponsors, board members, officers, coaches, assistants, appointees from any claims, liabilities, damages or
demands for any injuries to person or property sustained by my child resulting from or connected with their participation in any of its

I/We will be responsible for all the Binns Bengals’ uniform and equipment issued to my child. I/We agree to pay the replacement
cost of any or all of the issued uniform and equipment if it is not returned at season’s end as directed, upon demand, or is damaged
due to neglect. Outstanding indebtedness to Binns Bengals, Inc. that is not paid by the end of the season will eliminate the youth’s
ability to participate in the season ending banquet and receive his or her trophy. In addition, the youth will be reported to the Karl J.
Fulton League making the child ineligible to participate in any other organization within the Karl J. Fulton Pony League.

I/We understand that all children participating in the organization are required to participate in ALL fund-raising activities and abide
by all organizational rules. We also understand that the organization strives to provide each youth with game playing time, however,
due to the fact that the Karl J. Fulton Pony League is very competitive, there is NO guaranteed playing time.

The organization reserves the right to require a physician release for any youth the organization may have cause to be concerned with
their physical ability to participate in football or cheerleading for the sole purpose of protecting the child from injury.

In the event a parent or legal guardian is not present during an accident or injury incurred while the child is participating in an
organizational activity, do you authorize Binns Bengals, Inc. to seek emergency medical care for the child?
                                          YES                                                NO
Emergency Contact: (please provide one contact in the event that you cannot be reached)

Name:            Phone:

Relationship to youth: Grandparent

Parent(s) and/or legal guardian(s) please print, sign, and date below:                                Date: 2/9/2012

Print:         Sign: __________________________________________

Driver’s License #: _____________

Print:         Sign: __________________________________________

Driver’s License #: _____________

Witness (Binns representative): __________________________________________ Date__________________

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