Player InformationName* First Last Date Of Birth* Age*Age567891011121314151617Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*School InformationSchool Name*School District*Grade*Grade (as of Sept 1)Kindergarten1st2nd3rd4th5th6th7th8thFreshmanSophomoreJuniorSeniorParent/GuardianPlease select:*Please select:FatherMotherLegal GuardianName* First Last Email* Enter Email Confirm Email Work Phone*Cell Phone*Emergency Contact Information Same as above Emergency Contact NumberMedical InformationDo you have medical insurance?* Yes No Name of Personal Insurance CarrierAuthorizationMedical Authorization* Medical Authorization By the physical form attached I/We the parent(s) of the above named applicant hereby certify that my child has been EXAMINED by a physician and in doing so the physician DID NOT find any reason to disqualify him or her from participation in the SNOOP YOUTH FOOTBALL LEAGUE.Parents Authorization to Participate* Parents Authorization to Participate I/We the parents of the above named applicant to the SNOOP YOUTH FOOTBALL LEAGUE hereby give my/our approval to said applicant’s participation in any and all activities during the current season. The parent acknowledges, appreciates, and agrees that: The risk of injury to my child from the activities involved in this program is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and for myself, spouse, and child, I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases or others, and assume full responsibility for my child’s participation; and I myself, my spouse, my child, and on behalf on my/our heirs, assigns, personal representatives and next of kin, hereby release the other participants, sponsoring agencies, sponsors, advisors, and if applicable, owners and lessors of premises used to conduct the event (releases), with respect to any and all injury, disability, death, or loss or damage to person or property incident to my child’s involvement or participation in this program, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law. I, for myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, hereby indemnify and hold harmless all the above releases from any and all liabilities incident to my involvement or participation in this program, even if arising from their negligence, to the fullest extent permitted by law.Rules & Regulations* Rules & Regulations I/We willingly agree to comply with the program’s stated and customary terms and conditions for participation. I/We will furnish a Certified Birth Certificate and a copy of the current year’s report card of the above named applicant to the league officials. I/We give permission to the SNOOP YOUTH FOOTBALL LEAGUE to validate above named applicants school grades. I/We certify that the above named applicant is Scholastically eligible to participate. I/We agree to be financially responsible for Association/Youth equipment issued to applicant other than the normal wear and breakage during games and practice and I/We will reimburse the SNOOP YOUTH FOOTBALL LEAGUE for the loss and damage to said equipment. I/We as the parent of said candidate, understand it is the responsibility of the parent, candidate, team and Association to comply with any and all Rules & Regulations of said Association and the SNOOP YOUTH FOOTBALL LEAGUE. Any noncompliance with Rules & Regulations shall be cause for disciplinary action to be taken against said candidate, parent or team by said Association of the SNOOP YOUTH FOOTBALL LEAGUE.Insurance Disclosure* Insurance Disclosure * A DEDUCTIBLE MAY APPLY SEE YOUR CHAPTER PRESIDENT* The medical expense benefits of this plan are an “EXCESS” type benefit that picks up where other coverage’s leaves off. If the parent has any other Primary Coverage, whether individual, blanket or group coverage which provides benefits or services for, or by reason of, medical or dental care or treatment, then this plan, subject to the limits of the plan, will pay only the medical expenses not provided or reimbursable under your coverage. If the parent has no Primary Insurance coverage then this plan, subject to the limitations and deductibles (if any) of the plan, will provide Insurance coverage. If the parent has coverage with any Pre-Paid Medical Plans, such as (but not limited to) Cigna, FHP, Aetna, Kaiser, Blue Cross, the injured person must be taken to the pre-paid medical facilities for treatment. All claims must be filed within 90 days of the injury/ accident.Emergency Medical Release* Emergency Medical Release I/We the parents of applicant give our permission for any emergency treatment necessary either on the practice field or on the game field. I/We authorize any hospital and/or physician to perform emergency treatment for any injuries resulting from any scheduled Snoop Dogg Youth Football League functions including the supervised travel to and from said functions.Parents Acknowledgement* Parents Acknowledgement I/We certify, that to the best of my/our knowledge, all of the above information is accurate and correct and that any false information may be cause for disqualification of the applicant. I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without an inducement.Payment InformationRegistration Fee*New Cheerleader ($440)Returning Girls (must have uniform shell and jacket from 2017 season) ($350.00)Mascots ($390.00 ** *Note- 5 years and under must provide their own shoes.)Online Convenience Fee Price: $10.00 Total $0.00 This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card* American ExpressDiscoverMasterCardVisa Card Number Exp. Month010203040506070809101112 Exp. Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.