2021 Middle School Registration Form

Will you be paying the Full amount or the Payment Plan?*

Pay Full Amount
Payment Plan

Player Information

Player #1 Name:*

First Last

Player #1 Grade as of August 1*

Player #1 HS District: Middle School*

Player #1 Full Payment*

Price: $275.00

Player #1 Payment Plan*

Price: $100.00

Will you be registering a second player?*

YES
NO

Player Information

Player #2 Name:*

First Last

Player #2 Grade as of August 1*

Player #2 HS District: Middle School*

Player #2 Full Payment*

Price: $275.00

Player #2 Payment Plan*

Price: $75.00

Parent / Guardian Information

Father / Guardian Name:

First Last

Mother / Guardian Name:

First Last

Home Phone

Address

Street Address Address Line 2 City State ZIP Code

Father's Email

Enter Email Confirm Email

Mother's Email

Enter Email Confirm Email

Father's Cell

Father's Work Place

Father's Work Phone

Mother's Cell

Mother's Work Place

Mother's Work Phone

Emergency Contact's Name:*

First Last

Emergency Contact's Phone*

Insurance Information

Family insurance covers injuries incurred by youth sports?*

YES
NO

Insurance Company Name

Insurance Policy Number

PERMISSION MEDICAL RELEASE & WAIVER OF TRANSPORTATION LIABILITY

I hereby certify that I have knowledge of my child’s physical condition and state of health, and give my consent and permission for my son to engage in the active sports program of the Georgia Middle School Athletic Association and the Hiram Hornets Jr. Football Program. I do further certify that my son has no physical defects, disease, or disability that will in any way jeopardize his health or physical condition if he is allowed to take an active part in the program. I further state that I shall not hold any Person, Firm or Corporation backing any team, nor any of the Coaches of the Hiram Hornets Jr. Football Program, The Hiram Touchdown Club Inc officers, and the Hiram High School Football Program responsible nor liable for injuries incurred during practice sessions, practice games, regularly scheduled games, or transportation to and from games.

I further certify that by placing my signature on this document I have given permission to the Hiram Hornets Jr. Football Program to transport my child to a medical facility to secure treatment if deemed necessary at that time.

Parent / Guardian Consent*

I agree with and consent to all terms

Date*

Parent / Legal Guardian Signature Required

AUTHORIZATION FOR TREATMENT

I hereby give permission for the representation of the Hiram Hornets Jr. Football Program to secure immediate medical treatment for my child (Player Named Above), who is under the age of eighteen (18) years. I further give my permission for a medical facility, or a representative of the Hiram Hornets Jr. Football Program to provide immediate medical treatment for the above listed child. I understand that medical treatment is authorized in my absence, and that my signature below releases the Medical Facility and the Hiram Hornets Jr. Football Program and Hiram High School from liability regarding treatment if I cannot be reached. I further understand that I will be considered the responsible party for any charges incurred.

Parent / Guardian Consent*

I agree with and consent to all terms

Date*

Parent / Legal Guardian Signature Required

Please list below any existing medical condition, allergies and drugs being taken:

Refunds requested before the first official day of practice will be granted, minus a $50 admin fee.*

I agree with and consent to all terms

No refunds will be given after the first official day of practice, under any circumstances.*

I agree with and consent to all terms

All school issued items are to be returned in clean, satisfactory condition in order to have deposit checks returned.*

I agree with and consent to all terms

Payment Center

Payment Plan Option: Due dates - April 1 st ($100.00), May 1 st ($50.00), June 1 st ($50.00), July 1 st ($50.00), and August 1 st ($50.00).

Payments due will be adjusted accordingly if a player initially registers after April 1st . All payments for Player Registration Fees must be paid in full before football equipment is issued.

Payments can be made via Cash App at $HiramHornetFootball. Note the player's Name and Grade in the Cash App Memo Line.

To pay via credit card email hiramhornetfootball@gmail.com or treasurerhiramhornetfootball@gmail.com to schedule payment processing.

Contact the Hiram Touchdown Club for any questions or concerns (email: hiramhornetfootball@gmail.com)

Total Registration Fee

$0.00

Jr. Hornets Football Registration

Player Information

Player Information

Parent / Guardian Information

Insurance Information

PERMISSION MEDICAL RELEASE & WAIVER OF TRANSPORTATION LIABILITY

AUTHORIZATION FOR TREATMENT

Payment Center

Contact the Hiram Touchdown Club for any questions or concerns (email: hiramhornetfootball@gmail.com)