Gum Spring Panthers
Youth Football, Cheerleaders & Basketball     
Players
          Registration Form
                                                            Page 1 of 2

GUM SPRINGS YOUTH ATHLETIC ASSOCIATION
(GSYAA)
8100 Fordson Road
Alexandria, VA  22306
(703) 360-6088
http://www.geocities.com/gsyaasports

2007- 2008 FALL REGISTRATION FORM (Check One)
□  Football Fees				□   Basketball Fees		         □   Cheerleaders Fees
        July 1st to September - $75.00	   	     $65.00			              July 1st – Sept. - $65.00
        With Scholarship - $45.00                                      With Scholarship - $40.00               With Scholarship - $40.00

1.	Make checks payable to Gum Springs Youth Athletic Association or GSYAA.
2.	Registration form must be accompanied by check or money order with completed Fairfax County Scholarship Form.
PLAYER INFORMATION – PRINT LEGIBLY

Player Last Name: ___________________  First Name: ___________________  DOB: _________  Gender:  _______
Street Address: ____________________________________________________  Home Phone:  _________________
City/State/Zip:   ______________________
Fall 2007 Grade: _____________________      Fall 2007 School:       ________________________________________
Age as of 10/1/2007:  _________________      2006 Season Coach:  ________________________________________

Parent/Guardian Emergency Contact Information (Please provide accurate information)

Parent/Guardian 1
Full Name		Parent/Guardian 2
Full Name		
Relationship to Player		Relationship to Player		
Work Phone		Work Phone		
Cell Phone		Cell Phone		
Home Phone		Home Phone		

Medical Information
IMPORTANT NOTE:  If the player is under medical care or is on prescription medication, please provide a note   from his/her Physician.
Physician/Family Doctor		
Doctor’s Phone		
Insurance Carrier		
Policy Number		
Medical History (Allergies, Medications,
Special Conditions, etc.)		
Parent Permission/Agreement
Everyone will have to pay a portion or all of the Registration Fees.  THOSE WHO ARE ELIGIBLE TO RECEIVE A SCHOLARSHIP, will pay a reduced amount.  Those who are eligible for a scholarship must complete a scholarship form.  There are NO REFUNDS.  Equipment will be issued when the full registration fee is received.  Players will not be allowed to participate in the GSYAA program if payment is not paid in full.  Fees include rental of game uniform, football or cheerleading, and basketball equipment.  Uniforms and equipment are the property of GSYAA and must be returned by the end of the season.  I agree to pay the cost of any lost equipment issued to my child or me from GSYAA.

MEDICATION AUTHORIZATION:  Grant of Consent.  I hereby certify that my child is in good health and may participate in all activities.  In case of an emergency, I give my permission for my child to be given emergency treatment at any responsible accessible hospital.

LIABILITY WAIVER:  As the parent or legal guardian of the above named minor, I grant permission for the minor to participate in all activities of sports program.  I assume all  risk and hazards incidental to such participation, including transportation to and from such activities, and do hereby release and waive all claims against Gum Springs Youth Athletic Association, Sponsors, volunteers, and other participants.  I UNDERSTAND that GSYAA does not carry accident insurance.

Signature of Parent/Guardian _______________________________________________________________________
Print Name:  _____________________________________________________________________________________
Date:  __________________________

GSYAA
USE	Check No.	Amount Paid	Date Received	
									Page 2 of 2

GSYAA EQUIPMENT AGREEMENT

PLAYER NAME:  _____________________________________	WEIGHT: DIV:  __________

PARENT/GUARDIAN:  ________________________________  HOME:  _________________

Items Issued			Cost			Date Out		Date Returned

Cheerleader Uniform	         $65.00			____________		____________
Helmet			         $85.00			____________		____________
Chin Strap		         $15.00			____________		____________
Jaw Pads	                      $15.00			____________		____________
Shoulder Pads		         $60.00			____________		____________
Hips, Thigh, Knee Pads        $20.00			____________		____________
Practice Pants		         $25.00			____________		____________
Game Pants		         $30.00			____________		____________
Game Jersey		         $40.00			____________		____________

Mouthgards, supporters, and a cup are mandatory for all football players.  All purpose athletic shoes with molded cleats are recommended.  Replacement costs of all damaged or missing equipment are listed above.  Do not paint or drill holes in helmets.  Report all needed equipment repairs to your coach.  Uniforms should be cleaned after every game and please do not use bleach.

PARENT/GUARDIAN PLEDGE

The equipment that I, ___________________________________ , parent/guardian of _____________________________________, received, is the property of GSYAA.  This equipment is to be used solely for the purpose of GSYAA football, basketball and cheerleaders programs.  I understand that I will be charged for any missing or damaged equipment and uniforms at the rates listed above.  Equipment will be returned at once if I decide to withdraw my child from the program.  I will be released from all liability regarding the above, once all assigned equipment is returned in good condition.

Parent/s Signature:  ___________________________________________________________

Commissioner:   ______________________________________________________________

Head Coach:     _______________________________________________________________

DATE:  ___________________________________

Once completed, please email this back, to: gsyaasports@yahoo.com, or you can leave
it at the front desk at Recreation Center.