Participants Name___________________________________________

Address___________________________________ Development _______________________ Male Female (Circle One)

City___________ State ___ Zip _______ Birth Date _____________ Player’s Social Security # ___________________

Mother /Guardian Name ________________________________________ Home Phone ____________________

Father / Guardian Name ________________________________________ Home Phone _____________________

Mothers Employer _____________________________________________ Work Phone ______________________

Fathers Employer ______________________________________________ Work Phone _______________________

If Parents/Guardians cannot be reached, call: Name ________________________________ Phone____________________

Relationship____________________ Address _______________________________________________________________

Family Physician ________________________________________________ Phone ____________________________

Family Dentist __________________________________________________ Phone ____________________________

Do you use an inhaler for asthma or respiratory problems? Yes _____ No _____

Have you ever been diagnosed with or do you have any known medical problems that would be of concern for the heavy physical conditioning required for football (i.e.: cardiac problems, kidney problems, etc.) ? Yes ______ No ______

If yes please explain. __________________________________________________________________________________

____________________________________________________________________________________________________

Allergies: ( ) Penicillin ( ) Aspirin ( ) Other __________________________________________________

Medical Insurance Carrier _____________________________________ Ins. # __________________________________

Emergency Release:

If I/We cannot be reached in the event of an injury or illness to participant, I /We hereby agree to assume all expenses for transportation and medical treatment of the participant. I/We also consent to any treatment, surgery, diagnostic procedure or the administration of anesthesia, which may be deemed necessary, based on the medical judgment of the attending physician.

Parent/Guardian Signature _______________________________________________ Date___________________

Witness Signature _________________________________Position ___________________________ Date ___________

Note: League Insurance

It is understood that NCCFL has procured medical insurance, which is “TO SUPPLEMENT” my existing coverage. Said insurance is to cover medical expense resulting from injuries sustained while participating in the NCCFL program at NCCFL sanctioned events only! In addition dental claims are covered, but are not to exceed $50.00 per sound tooth. This insurance is between parent/guardian and the insurer. The policy carries a deductible, which NCCFL does not cover. You must provide the insurer with a Statement of benefits from your own insurance before the insurer will pay on the claim. All claims must be dealt directly with the insurers agent. NCCFL will assist in filing the initial claim only!!