JUNIOR STATESMEN FOOTBALL CLUB REGISTRATION FORM

 

JUNIOR STATESMEN FOOTBALL CLUB

Planting the seeds for Webster Groves Varsity Football Program

Building Champions - one player at a time!

 2022 REGISTRATION FORM


  PLAYER REGISTRATION FEE $250.00         



JUNIOR STATESMEN FOOTBALL CLUB REGISTRATION FORM

2022 Season – Player Registration Fee $ 250.00

A separate, additional $150.00 equipment deposit fee is required prior to equipment issue.  Please use separate check or cash. Equipment deposit will be held by League and returned when equipment is returned. Late returns and missing/damaged items will be deducted from Equipment Deposit (See itemized list at bottom).

INSTRUCTIONS: Mail form with registration fee payable to:  JUNIOR STATESMEN FOOTBALL - c/o Brandon Patterson – 1275 Rockridge Place – Kirkwood, MO  63122.      Phone: 314/416-0100

PLAYER INFORMATION

Name:________________________________(___________)          Phone:________________ E-Mail:__________________

                   (Last)                                  (First)                                       (Nickname)

Address: ____________________________________  City:__________________Zip:_________

Grade entering in fall: ___ 5th ___ 6th___ 7th ___ 8th      Birth Date:____/____/____     School:______________________

PARENT/LEGAL GUARDIAN INFORMATION

Father:_______________________________        Mother:________________________________

Phone: (if different than player)__________________              Phone: (if different than player)____________________

Work/Cell Phone:______________________            Work/Cell Phone:________________________

Other emergency contact person: ________________________________  Phone:________________

                                                                                  (name)                                                (relationship)

PARENT PERMISSION – RELEASE – AUTHORITY FOR TREATMENT & INSURANCE VERIFICATION

PERMISSION: I/we hereby give my/our consent for my/our child/ward to participate in all activities of the Junior Statesmen Football Club (JSFC).

RELEASE: I/we hereby agree to hold the Webster Groves School District, in which the JSFC is affiliated in name only, AND all agents, representatives, coaches and volunteers of the Junior Statesmen Football Club, harmless from any and all liability, actions, causes or debts, claims or demands of every kind and nature whatsoever which may arise by or in connection with the participation by my/our child/ward in any activities related to the JSFC program.

EMERGENCY TREATMENT: If I/we cannot be reached, and in the event of an emergency, I/we also give my/our consent for the JSFC to obtain through a physician or hospital of its choice, such medical care as is reasonably necessary for the welfare of my/our child/ward if said child/ward is injured in the course of JSFC activities.

INSURANCE VERIFICATION: I/we verify that my/our child/ward is covered by basic accident insurance for the current school year with:

(Name of Insurance Company/Carrier)                                                                                                                                       (Policy or ID Number)

Signature below signifies acceptance by ALL custodial parents/legal guardians.

PARENT/GUARDIAN SIGNATURE:___________________________________  DATE:_________

*************************************************JSFC USE ONLY *******************************************************

* REGISTRATION FEE:  Amount $________   Ck or M.O.#________ or cash $______  Recd. By______  Date:______

* Physical Exam/Medical Approval Form:   Received by:________    Date: _________

* EQUIPMENT:  Issue Date: ______  Deposit Paid: Amount: $_________ ck#:_____ _   Recd By_____ Date______

* EQUIPMENT RETURN: Date:_______  Dep. Rtned: Amt:$________ (Less any deductions(s): $20-late turn-in, and

 for missing, broken, damaged or excessively misused items: (Check pertinent item) ___Helmet: $95 if lost, $50-$75 if damaged/repair necessary. ___Shoulder pads: $60 lost - $20-30 if damage/repair.  ___ Pants-Game: $35-lost, damaged or misused.  ___Pants-Practice: $25-lost/damaged. ___Jersey-Game: $35 lost, $20-25-damaged/misused. ___Jersey-Practice: $20-lost or damaged.  ___Thigh, knee, tail, hip, belt: $4.00 per item-lost or damaged.                                                       TOTAL DEDUCTIONS: $_________  JSF Initials_________