CHESTERFIELD QUARTERBACK LEAGUE

APPLICATION TO PLAY FOOTBALL

Association_______________                                                     CQL USE ONLY

             Circle one                                                        PL       OP         OPC          PW        S

Flag       Minor             Junior      Senior

6&7      8&9                 10&11    12&13

Player ___________________             __________________________             ________

                        Last Name                                               First Name                                            MI

Address ______________________________                         ________________

                                    Street                                                                               Phone Number

                _____________________________________

                                City, State, Zip Code

Date of Birth ______________                                 Age (as of July 31 st) _______

__________________________                                 _________________________

        Elementary School Boundary                                                                 School Attending

Did Child Play Last Year?    YES      NO                   If yes, for who _____________

I/We, the parents of the above, a candidate for a position on the _________________ team, which is a

                                                                                                                            Association

Member Association of the Chesterfield Quarterback League, Hereby gives my/our approval of his/her participation in any and all League sponsored activities.

I/We assume all risks and hazards incidental to such participation including transportation to and from the activities and I/We do hereby waive, release, absolve, indemnify and agree to hold harmless the Chesterfield Quarterback League, the Organizers, Sponsors, Supervisors, Participants and Persons transporting my/our son/daughter, except to the extent and in the amount covered by accident or liability insurance.

I/We shall furnish a certified Birth Certificate or certified legal proof of birth or other legal proof as may be requested by the League for the above candidate at the time and place of his/her initial weigh-in or at some other time or place designated by the Commissioner.

I/We grant the Commissioner, Chesterfield Quarterback League, permission to verify, if necessary, my/our child’s school records pertaining to birth date and residence information only.

Parent/Legal Guardian Signature ___________________________________    Date ___________

Parent/Legal Guardian Signature ___________________________________    Date ___________