The Wilkes Yellow Jackets
would like to thank
all the members of
Peace Haven Baptist
Church for letting us
use your field for practice. The VFW for providing us a
place to play. The Wilkes Rec. Dept. for
keeping the fields up. The North Wilkesboro Police Dept. and North Wilkesboro Recreation Dept. We would also like to thank American Drew and Terry Barlow of Plugs Boom Trucks for helping put up our new scoreboard.
THANK YOU
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YELLOW JACKET FOOTBALL & CHEERLEADING SIGN UP FORM
(Just click here for the permissionform.doc for easier printing.)
You Must Turn In To The Coach At The First Practice
NAME:_________________________________________ BORN:____________
Street Address___________________________ City ____________
State _____ Phone #______________
I/We, the parents of the above named candidate for a position on a Yellow Jacket Football/Cheerleading
team, hereby give my/our approval to his/her participation in any and all Yellow Jacket Football/Cheerleading
activities during the current season. I/We assume all risks and hazards incidental to such participation including
transportation to and from the activities. I/We do hereby waive, release, absolve, indemnify and agree to hold
harmless, the local organizers, sponsors, supervisors, participants, and persons transporting my/our child to and from
activities, for any claim arising out of an injury to my/our child, except to the extent and in the amount covered by
accident or liability insurance.
I/We agree to return upon request the uniform and other equipment issued to my/our child in as good a
condition as when received except for normal wear and tear. I/We further state that the Parent’s Manual and rules of
the league have been read and I/We will abide by those rules and regulations.
THIS LINE MUST BE SIGNED BY BOTH PARENTS. If not, give reason for vacant line.
FATHER’S SIGNATURE:_____________________________________ DATE:________
MOTHER’S SIGNATURE:_____________________________________ DATE:________
Please list your personal insurance carrier and policy number:__________________
If you do not have insurance for your child, please check: NO___________
The Yellow Jacket Football/Cheerleading Insurance Policy is a Secondary Coverage Policy. (Secondary Coverage
Policy simply means that this policy will pay after the Primary Insurance Policy (coverage by the parent) has paid.) If
there is not a Primary Insurance Policy, the Yellow Jacket Football/Cheerleading Insurance will cover expenses.
However, we must have proof that the child in not covered by a Primary Insurance Policy. In addition, when a claim is
filed, we must have a copy of the Explanation of Benefits from the Primary Insurance Policy. Our policy does have a
$100 deductible.
For Emergencies a parent will be called and if unable to contract a parent the Emergency Contact will be called.
Emergency Contact Person:
Name:_____________________________________Phone:________________
Relationship:_____________________________________
In case the parent, nor the Emergency Contact Person cannot be reached, I give the Coach or Cheerleader
Coordinator permission to consent for Emergency medical treatment as deemed necessary by the nearest
Emergency Department Physician.
Legal Guardian Signature:________________________________________________
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7-8 JACKETS
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7-2
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5-6 JACKETS
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5-3
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3-4 JACKETS
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2009 Champs
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5-2
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1-2 JACKETS
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4-2
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