NCYA
FOOTBALL AND CHEERLEADING SIGN-UP
Call about our FREE CAMPS!!!!!! Sign-up Today!!!!!!
Ages 7 – 14
Name
__________
Address
School
Age
___
D.O.B
________ City
__________
Parents/Guardian Name
Sex M/F ______
Zip Code
____________
Grade Next Yr ________________________
Home Phone
___________________
Cell Phone
______ E-mail __________________________________________
Any Medication or special needs yes / no if yes explain:
_____________________________________________________________________
NCYA HOLD HARMLESS POLICY
WAIVER AND RELEASE OF ALL CLAIMS
I recognize and acknowledge that there are certain risks of physical injury to participants in this program and I voluntarily agree to assume the
full risk of any and all injuries, damages, or loss, regardless of severity that my minor child/ward or I sustain as a result of participating (including
transportation, when provided). My child has been physically cleared to participate in sports by his/her physician. I further agree to waive and
relinquish all claims I or my child/ward may be entitled to as a result of participating in this program against City of Black Jack, the North County
Youth Association, and The Gateway Football League, including officials, agent’s volunteers and/or employees of the said parties and including
claims resulting from the City's negligence. I agree to the unreserved use of my child's name and/or likeness (including photographs, videotapes
and other depictions) for publicizing North County Youth Association programs and events. I have read and fully understand the above
information.
Signature
Participant or parent/guardian if participant is under 18
Date __________________________
For questions or concerns please contact
Dana Kirksey at: (314) 749-0054 or dana.kirksey@n-c-y-a.com or
Van Swingler at: (314) 226-5057 or van.swingler@n-c-y-a.com
For more info visit www.n-c-y-a.com or visit us on Facebook
For office use only
Team
2nd grade – Coach JR
_____
rd
3 grade – John James _____
4th grade – Coach Snow _____
5th grade – Coach Smokey _____
6th grade – Coach Van
_____
th
6 grade – Coach Gilyard _____
7th grade – Coach Dre
_____
7th grade – Coach Holmes _____
Jersey #/size __________
Shoe size
__________
TShirt size
__________
Birth Cert. on file _______
Report Card on file _______
Account Balance
1st payment
2nd payment
3rd payment
TJ’s Pizza Sold
TJ’S Profit
Lock In Tickets
$195.00
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