First Name :
Last Name :
Phone :
Address :
City :	Coeur d'Alene Hayden Hayden Lake Dalton Rathdrum Post Falls Choose Not Listed Harrison Athol
Zip code :	83815 83814 83816 83835 83858 83854 Choose Not Listed 83833
Birthdate :	1 2 3 4 5 6 7 8 9 10 11 12   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
School :	Atlas Dalton Canfield Borah Bryan Charter Ramsey Sorensen Skyway Winton Fernan Lakes Hayden Meadows CHS LCHS Woodland Choose Garwood Home School Lighthouse Prarieview Post Falls Christian Holy Family NI Christian Sunrise River City Not Listed Genesis Prep Betty Kiefer
Grade Sept of 2011	0 3 4 5 6 7 8
Tee-Shirt Size :	Choose Y Large A Small A Med A Large A XL A XXL Y Med A XXXL
Team Last Year :	Choose None Last Year Any Bucs Chargers CHS Mid CHS North CHS South Fitz Jaguars Jets LCHS Mid LCHS North LCHS South Packers Panthers Patriots Raiders Rams Redskins Seahawks Steelers Vikings
A player cannot play more than one year of each division.

We, the parents of the above named player of a CDA Jr. Tackle Football team, hereby give our approval for participation in any and all football activities during the current season. We assume all risks and hazards incidental to such participation including transportation to and from the activities; and we do hereby waive, release, absolve,indemnify, and agree to hold harmless the CDA Jr. Tackle Football Association, their organizers, sponsors, supervisors, participants and persons transporting our child, except to the extent and in the amount covered by accident and/or liability insurance held by the local league. We the parents, agree to be responsible for the football uniform. If not returned at the end of the season, replacement costs for said uniform will be paid by the signee.						Yes I Agree Choose Agree Disagree
Participants must furnish shoes, practice jersey, and their own pants with pads. CDA Jr. Tackle Football will issue a helmet, game jersey, shoulder- pads, and a mouthpiece. All players must have a physical - Prior to practice. Physicals are valid for 2 seasons.						Yes I Agree Choose Agree Disagree
CONSENT FOR MEDICAL TREATMENT: As the parent/guardian of the above named player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependent.						Yes I Agree Choose Agree Disagree
I			On this date    give my consent.
Fathers Name :
Mothers Name :
Emergency contact name :
Emergency contact Phone :
E-Mail Address :
This is an all volunteer league please indicate area of service you would like to be involved in :
Field set-up	Chain Crew	Snack bar/concessions
Score Board	Field Paint	Team Mom
I would like to be a Sponsor
CDA Jr. Tackle desires quality-coaching applicants. Are you interested in a coaching/assistant position?			Yes
I do hereby agree to play CDA Jr. Tackle Football with any team to which I am assigned for the 2012 season.
Yes I Agree			Choose Agree Disagree
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