SIPlive: Duchesne City Recreation (L.?)

Duchesne Recreation Football
For kids grades 3rd - 6th
Grades are based on the grade the child will be in this coming school year.
****NO REFUNDS****

Early Bird Registration May 20 - July 28

$115 per player without jersey

$130 per player with jersey

Late Signup after July 28th

$130 per player without jersey

$145 per player with jersey

Registration fees include helmet, pads, and pants (both practice and game pants).
Parents are responsible for providing their child with a mouth guard.
If you want a team picture there will be an extra $15.00 on top of the registration fee.

Practice will be held in Duchesne and games will be on Saturdays in Duchesne, Roosevelt, Vernal, Ft. Duchesne, and North Summit. Once a player is registered they will be contacted by their coach to come in for equipment sign out. At that time the parent/guardian will need to provide a check for $120 as a deposit for the equipment. This check will NOT be cashed unless the equipment is not returned at the end of the season.

You may request up to 3 numbers for jersey, number assignments will be determined by upper class jersey numbers.

Registration With Jersey:

$145.00

Quantity:

Item Subtotal:

$0.00

Request Jersey Number	[1]
Participant's First and Last Name		[1]
Jersey Size		[1]
Pant Size		[1]
Participants Grade for the upcoming school year		[1]
Request Jersey Number	[2]
Participant's First and Last Name		[2]
Jersey Size		[2]
Pant Size		[2]
Participants Grade for the upcoming school year		[2]
Request Jersey Number	[3]
Participant's First and Last Name		[3]
Jersey Size		[3]
Pant Size		[3]
Participants Grade for the upcoming school year		[3]
Request Jersey Number	[4]
Participant's First and Last Name		[4]
Jersey Size		[4]
Pant Size		[4]
Participants Grade for the upcoming school year		[4]
Request Jersey Number	[5]
Participant's First and Last Name		[5]
Jersey Size		[5]
Pant Size		[5]
Participants Grade for the upcoming school year		[5]
Request Jersey Number	[6]
Participant's First and Last Name		[6]
Jersey Size		[6]
Pant Size		[6]
Participants Grade for the upcoming school year		[6]
Request Jersey Number	[7]
Participant's First and Last Name		[7]
Jersey Size		[7]
Pant Size		[7]
Participants Grade for the upcoming school year		[7]
Request Jersey Number	[8]
Participant's First and Last Name		[8]
Jersey Size		[8]
Pant Size		[8]
Participants Grade for the upcoming school year		[8]
Request Jersey Number	[9]
Participant's First and Last Name		[9]
Jersey Size		[9]
Pant Size		[9]
Participants Grade for the upcoming school year		[9]
Request Jersey Number	[10]
Participant's First and Last Name		[10]
Jersey Size		[10]
Pant Size		[10]
Participants Grade for the upcoming school year		[10]

Registration With No Jersey:

$130.00

Quantity:

Item Subtotal:

$0.00

Participant's First and Last Name				[1]
What number is currently on your jersey?				[1]
Pant Size				[1]
Participants Grade for the upcoming school year				[1]
Participant's First and Last Name				[2]
What number is currently on your jersey?				[2]
Pant Size				[2]
Participants Grade for the upcoming school year				[2]
Participant's First and Last Name				[3]
What number is currently on your jersey?				[3]
Pant Size				[3]
Participants Grade for the upcoming school year				[3]
Participant's First and Last Name				[4]
What number is currently on your jersey?				[4]
Pant Size				[4]
Participants Grade for the upcoming school year				[4]
Participant's First and Last Name				[5]
What number is currently on your jersey?				[5]
Pant Size				[5]
Participants Grade for the upcoming school year				[5]
Participant's First and Last Name				[6]
What number is currently on your jersey?				[6]
Pant Size				[6]
Participants Grade for the upcoming school year				[6]
Participant's First and Last Name				[7]
What number is currently on your jersey?				[7]
Pant Size				[7]
Participants Grade for the upcoming school year				[7]
Participant's First and Last Name				[8]
What number is currently on your jersey?				[8]
Pant Size				[8]
Participants Grade for the upcoming school year				[8]
Participant's First and Last Name				[9]
What number is currently on your jersey?				[9]
Pant Size				[9]
Participants Grade for the upcoming school year				[9]
Participant's First and Last Name				[10]
What number is currently on your jersey?				[10]
Pant Size				[10]
Participants Grade for the upcoming school year				[10]

Picture(s):

$15.00

Quantity:

Item Subtotal:

$0.00

Total:

$0.00

Parent/Guardian Information

First Name:	Last Name:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:	Email:

In Emergency Notify

Emergency Phone Number

Payment Information

Method of Payment:

	Update name from Parent/Guardian Information
Name of Individual on Checking Account: Name of Individual on Savings Account: Name of Business on Checking Account:
Bank Routing Number:
Bank Account Number:

Credit Card Number:
Expiration Date:	/
Card ID (CVV2/CID) Number:	What is the Card ID?

Cardholder Information (exactly as it appears on your statement)
	Update from Parent/Guardian Information
Cardholder's Name:
Billing Street:
Billing ZIP/Postal Code:

Release of Liability/Consent Form:

This consent is for the 2019 season. The participants listed above are physically fit and otherwise able to participate in this program. I understand the program will be supervised and I further understand Duchense City Recreation Volunteer and its employees willnot be held liable for any accidental injury incurred while the participants listed above are participating or while being transported to and from games. I authorize emergency treatment for any accident or illness and consent to allow Duchesne City and its volunteers to use their discretion in administering First Aid medical care to all participants listed above.

I Agree

I have read and agree to the above disclaimer


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