2010 Online Registration

PLEASE NOTE: REQUIRED FIELDS ARE UNDERLINED.

FOOTBALL PLAYER OR CHEERLEADERS - FULL NAME:

GENDER: MALE FEMALE SPORT: FOOTBALL CHEERLEADING

HOME ADDRESS: CITY: ZIP:

DATE OF BIRTH: * Please enter date as [ dd-mmm-yyyy ]: Example: 22-FEB-2010

HOME PHONE: ** Please enter phone numbers using the following Example: 618-111-2222

CELL PHONE:

EMAIL ADDRESS (1):

EMAIL ADDRESS (2):

NAME OF PARENT OR LEGAL GUARDIAN:

SCHOOL: GRADE (2010-11 SCHOOL YR):

EMERGENCY PHONE NUMBER #: ** INSURANCE CARRIER:

PHYSICIAN NAME: PHYSICIAN PHONE #: **

BROTHERS / SISTERS REGISTERED:

SPECIAL REQUEST (COACH, PLAYER, PLAY DOWN OR UP, CAR POOL, ETC.):

I, the undersigned, verify that the above information is correct.  I understand that the MASCOUTAH LITTLE INDIANS YOUTH FOOTBALL PROGRAM will not be held liable for any injuries incurred during practices or games.  I also understand that the insurance provided by the SOUTHWESTERN ILLINOIS YOUTH FOOTBALL CONFERENCE is a secondary type of insurance with the primary insurance being that of the parent or guardian.  I further agree to allow the school indicated above to release information to the MASCOUTAH LITTLE INDIANS YOUTH FOOTBALL PROGRAM as to the applicant’s age, grade, and school district.  Furthermore, by submitting this online form, I am committing to reimburse the MASCOUTAH LITTLE INDIANS YOUTH FOOTBALL PROGRAM for equipment not returned within thirty (30) days after the last game.

REGISTRATION FEES WILL NOT BE REFUNDED AFTER PRACTICE BEGINS.

WE MUST HAVE A COPY OF EACH PLAYER’S BIRTH CERTIFICATE ON FILE.  PLAYERS WHO DO NOT HAVE BIRTH CERTIFICATES ON FILE WILL NOT BE ALLOWED TO PLAY DURING GAMES.

VOLUNTEER POLICY:  THE MASCOUTAH YOUTH FOOTBALL PROGRAM IS A NON-PROFIT ENTITY AND RELIES ON VOLUNTEERS FOR GAME DAY PREPARATIONS AND ACTIVITIES (e.g., field set-up, concession stand operations, etc.).  WE WILL COLLECT A VOLUNTEER FEE WHEN WE ISSUE PLAYER EQUIPMENT FOR THE 2010 SEASON.  WE WILL RETURN THE VOLUNTEER FEE AFTER THE VOLUNTEER COORDINATOR DOCUMENTS COMPLETION OF THE REQUIRED VOLUNTEER SERVICE.  THE VOLUNTEER IS PER FAMILY, NOT PER CHILD.  FAMILIES MAY OPT OUT OF VOLUNTEER SERVICE BY DONATING THEIR VOLUNTEER FEE TO THE PROGRAM.

I HAVE READ AND UNDERSTAND THE ABOVE FORM AND AGREE TO THE CONDITIONS THERE OF:

CURRENT DATE: * Please enter date as [ dd-mmm-yyyy ]: Example: 22-FEB-2010

PARENT OR GUARDIAN NAME:

After clicking the below submit button you will be redirected to our Google Checkout page. At that time you can pay your 2010 football or cheerleader registration fee as listed below. This application will not be processed until we have received comfirmation of your REGISTRATION FEE payment. You will be notified via email when your credit card payment has been received from . If you have any questions about online registration, please contact our Membership Director Christina Schriever at membership@mascoutahlittleindians.org

REGISTRATION FEE'S:

FOOTBALL - $125 plus a $4.05 online payment fee. Total online registration cost will be $129.05.

CHEERLEADING - $60 plus a $2.10 online payment fee. Total online registration cost will be $62.10.

PLEASE NOTE: If the name on the credit card being used for payment is different than the name give in the "PARENT OR GUARDIAN NAME" field above then enter that name on the credit card here:

CLICK SUBMIT TO PROCESS YOUR REGISTRATION: