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!
2023 REGISTRATION FORM
PLAYER REGISTRATION FEE $300.00
JUNIOR STATESMEN FOOTBALL CLUB REGISTRATION FORM
2023 Season – Player Registration Fee $ 300.00
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: 314-660-8029
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_________