2018 FOOTBALL

REGISTRATION

2018 TACKLE FOOTBALL SEASON FOR ONLY $150.00

8U (7&8 Year olds) $150.00
10U (9&10 year olds) $150.00
12U (11&12 year olds) $150.00
Flag Football (5, 6 , 7) year olds) $60.00
Cheer (6-12 years old) $150.00
 Birthdays must be on before August1st

___ 2018 FOOTBALL SEASON _X___Flag Football ___ Cheer

Birth Date: May 28, 2013_________________________ Age: __5yrs______

Child’s Name: ______Kellen Brown___________________________________________________

Home Phone: _____336-512-6547_____________________________________________________

Address: ______5811 Landerwood Dr.______________________

City/State/Zip: ____Greensboro, NC 27405_________________________________________

Day Phone: _336-512-6547_____________________ Cell Phone: ____336-512-6547_________
Email Address: ___rrday04@yahoo.com______________________________________________
Medical Information (Chronic Ailments):

_________None________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
List any Medications your child is presently taking:

__________None_______________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

Emotional, Behavioral, Learning Disabilities:

___________None______________________________________________________________________
_____________________________________________________________________________________

Are there any custody issues involving your child that the director and staff should be made aware of?
_____________None____________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

As the child’s parent/guardian, I understand the Northeast Athletic Association seeks to provide
supervised games for the kids. I, the parent, of the player, do hereby give my approval of his/her
participation in any and all activities during the current season. I assume all risks and hazards incidental
to the conduct of the activities and further release, absolve, indemnify and hold harmless the
Association, the organizers, sponsors, and supervisors/coaches, and/or all of the above mentioned. In
case of injury to my child, I hereby waive all claims against the organizers, sponsors and any of the
supervisors appointed by them. I likewise release from any responsibility, any person transporting my
child to and from activities.

Parent/Guardian Signature: ______Keisha Brown____________________ Date: _06/28/18____

Insurance Information
Child’s Name: __Kellen Brown_____________ Birth Date: ____05/28/13_____ Age: 5yrs_____

Insurance Company: ___NC Medicaid______________________________

Policy Holder: ____________________________________________

Subscriber Number: _______________________________________

Group Number: ___________________________________________

Pediatrician: __Triad Adult and Peds_________________ Telephone Number: __336-272-1050_____

EMERGENCY CONTACT INFORMATION

Name: __Keisha Brown_______________________ Relationship: _____Mother________________

Home Phone: _____________________________ Cell Phone: _________336-512-6557__________
Address: ________Same Address____________________________________________________

City/State/Zip: ____________________________________________________________________

Name: ____Len Brown_________________________ Relationship: ____Farther_______________

Home Phone: _____________________________ Cell Phone: ____336-343-5388_____________
Address: ______Same Address_________________________________________________________
City/State/Zip: _____________________________________________________________________

Name: ___________________________________ Relationship: __________________________

Home Phone: ______________________________ Cell Phone: ___________________________
Address: __________________________________________________________________________
City/State/Zip: _____________________________________________________________________

Parent/Guardian Signature: Date:

___Keisha Brown___________________________ _6/28/18______

Copy of Birth Certificate and

Physical is needed