NEYSA Cheerleader Registration Form
Cheerleader Name								Phone Number
Address
	Street				City		State		Zip
Current Grade				Age				Birthdate
Parent/Guardian								Phone Number
E-Mail							Cell Number
I/We have insurance that provides liability insurance and medical payment coverage with the following insurance company:
Insurance Co.							Policy #
Name of Policy Holder:
I\we give consent to have my\our child taken to the nearest hospital in case emergency treatment is necessary:
My\our hospital preference is (circle one):					YORK HOSPITAL             MEMORIAL HOSPITAL
My\our child has the following Allergies or Medical conditions
My\our child is on the following Medications
Other emergency contact:								Phone Number
Relationship to child:							Cell Number
As the parent\guardian of _____________________________________, a NEYSA cheerleader, I\we will take full responsibility for the NEYSA cheerleading uniform.  I acknowledge that the uniform is to be worn ONLY to games.  If the uniform should get lost, stolen, ruined, or permanently marred, I\we take full responsibility for it and will pay NEYSA for the current replacement (approximately $200.00).
I/We release NEYSA, Northeastern School District, their affiliates, employees, and volunteers from any personal injury, accident or other claims resulting from my/our child's participation.  I/We agree to indemnify and hold harmless the above named organizations, affiliates, employees, and volunteers from such claim, liability, legal action, and all attorney fees which are or could be claimed by my/our child or by me/us.  I/We intend to be legally bound.
By signing this form I agree and confirm all of the above information to true and correct.
Parent/Guardian Signature								Date
I'm interested in:		Coaching			Team Mom
Uniform Size:		Top			Bottom