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PLEASE NOTE THAT SUBMISSIONS MUST INCLUDE A COPY OF BIRTH CERTICATE AND PHYSICAL EXAMINATION FORM.
AS IT APPEARS ON BIRTH CERTIFICATE
Please include a secondary number in case the first cannot be reached.
Please complete one form per sport and per player
$55.00 per first child for:
Youth Football & Cheerleading ($10 late fee per child)
$50.00 per additional child for:
Youth Football & Cheerleading
**All Fees must be paid in full before participation. Refunds are subject to a $20.00 Administrative fee. No refunds will be issued after July 22, 2022**
I/We are willing to participate in the following activities for the Farmville Recreation Department’s Youth Football & Cheerleading program.
COACHES: Please submit this registration and the NAYS certification to the Recreation Department. (email@example.com)
I/We consent to our child participating in the Farmville Recreation Department Programs. In participating in Recreation Programs, sponsored by The Town of Farmville, I hereby acknowledge that I/We understand that there are risks of accidents resulting in bodily harm arising out of those activities. I/We understand that Recreation activities are planned with the safety of the participants in mind. In case of emergency, accident or illness, if I/We am not present I/We hereby give our permission for the coach or representative of the Recreation Department to obtain any required medical attention my child may need. I/We will notify the coach of any physical limitations (allergies, hearing, sight, etc) or other additional information they need to know about my/our child. I/We further acknowledge that my child has the physical capacity reasonably necessary to engage in Recreation activity for which I have enrolled. I/We agree to be the party responsible for all medical expenses which are incurred in my behalf. It is understood and agreed that the Town, it’s Mayor, Town Council, Boards, employees, volunteers and agents shall be held harmless against all claims, damages, loss or expenses including attorney’s fees arising out of or resulting from participation in recreation programs. I/We agree any pictures taken may be used for future promotions for the Town of Farmville.
Type Parent/Guardian name
Please upload an image or pdf scan of the participants birth certificate here. This is required for both youth football and cheerleading.
Please be sure that the attached document is not blurry or distorted.
Please upload an image or pdf scan of the participants physical examination form here. This is required for both youth football and cheerleading.
For more information contact the Farmville Recreation Department at (434) 391-1125, or e-mail: firstname.lastname@example.org.
This field is not part of the form submission.
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