Registration Forms
(For PFL use only)
Check# ________ Amount $_______ Date ____________ Received by __________
League Fee: $ 30.00 per student or $50.00 for two students. Please pay by check, No Refunds
* No one will be excluded from playing for financial reasons. Questions should be directed to Ryan
Klinedinst, League President (536-5704)
* Please pay by check payable to: Prairie Football League, Inc.
* Payments are due Registration Day. A receipt must be presented to pick up your equipment.
(Please Print)
Player’s Name: Age: Grade, this fall __________
Parent’s Name: ________________________________________________________________
Address: ____________________________________________________________________
School: _____________________________________________________________________
Date of Birth: / / Telephone Number: ( )_____________________________
Please provide the following information about the player. It will be helpful in selections of teams and
issuing equipment. Did you play in the P.F.L. last year? Yes No What position? _________
Height: ______ Weight: ______ T-shirt size: (circle one) Adult size S M L XL XXL
Is the player covered by medical insurance: Yes No
Insurance Company Name: ___________________________ Policy # _______________________
No 4th, 5th, or 6th grader who has turned 13 years of age prior to August 1, and/or weighs more than
225 lbs. is eligible to play in the League.
If you have more than one child participation in the League, would you prefer they play on the same team?
Yes No Names of Children: _______________________________________________
Assistants are needed for each team. Interested individuals should note below if they would be willing
to help this season.
Assistant Coaching ___________ Reffing/Sidelines _____________ PFL Board Member ___________
Name _____________________________________________ Phone _________________________
Prairie Football League Incorporated
Waiver
I give my consent for to participate in the Prairie Football League,
recognizing that the League is a contact football league open to 4th, 5th, and 6th grade youths who have
not reached their 13th birthday by August 1, and who weigh less than 225 lbs. I have reviewed and I
am familiar with the Prairie Football League rules.
I am aware that football is a collision sport creating a risk that my child will be injured as a result of
his participation in the League. On behalf of my child and myself, I hereby release, waive and indemnify
the Prairie Football League, Inc., its Board of Directors, its coaches, its participants, Fairfield Community
School Corporation and any staff, coach or employee of the Fairfield Community School Corporation from
any liability resulting from any injury or illness incurred by my child during his participation in the League.
I am further aware that the League does not carry any medical insurance to cover any injury or illness that
my child may suffer. I have medical insurance that will cover my child in the event of injury or illness, or
I agree that I will pay all medical expenses resulting from any injury or illness that my child may suffer
while he participates in the Prairie Football League, indemnifying the League against any such expense.
I authorize the personnel of the Prairie Football League, Inc., to act for me according to their best
judgment in an emergency requiring medical attention.
___________________________________ ______________
Parent or Guardian Date
Waiver and Release Roster
I, the undersigned player, acknowledge, agree and understand that:
1. Voluntarily and of my own free will, I elect to participate as a member of the football team and league
indicated below.
2. I understand that there are certain risks and hazards involved in participating in football that may result
in injury or death to me or other players, including but not limited to those hazards associated with weather
conditions
3. I understand that the very nature of the game of football is hazardous and risky, including, but not limited
to, the acts of blocking, tackling, passing and catching of the ball, running, jumping, stretching, sliding, diving,
and collisions with other players and with stationary objects, all of which can cause serious injury or death to
me and to other players.
Further, I the undersigned player, agree that in consideration for the right to play as member of the league
designated below and in consideration for permission to play on the field arranged by the team or league:
1. I voluntarily elect to accept and assume all risks of injury incurred or suffered by me (a) while practicing or
playing as a member of the league so designated, (b) while serving in a non-playing capacity as a team member
during practice or play by other teams or by other players on my team, and (c) while on or upon the premises of
any and all of the courts arranged for by my team or league for practice or play.
2. I release, discharge and agree not to sue the league designated below, the field owner or other entity designated
below, for any claim, damages, costs or cause of action which I have or may in the future have as a result of injuries
or damages sustained or incurred by me from whatever cause including but not limited to the negligence, breach of
contract of wrongful conduct of the parties hereby released.
I acknowledge that I have read and understand each and every one of the provisions in this waiver and release
form, and agree to abide by them.
Prairie Football League, Inc. Fairfield Community Schools
Name of League Field Owner
______________________________ _____________________________ __________________________________
Name of Player Street Address City, State, Zip
___________________________________________ ________________
Parent or Legal Guardian Signature Date
Medical History Form
Players Name: ____________________________________________________
This form will constitute a medical history for our information. A complete physical exam by your family
physician is advised if you feel it is necessary. Please circle the appropriate answer for the following questions.
Please explain further on a “yes” answers.
1. Has your child ever shown any indication toward:
Yes No Being a diabetic?
Yes No Any type of seizures?
Yes No Any chronic disease or health problem?
Yes No Liver, spleen or kidney problems?
Yes No Heart or circulatory problems?
Yes No Respiratory problems?
Yes No Allergies?
Yes No Vision or hearing problems?
Yes No Hernia or genitalia problems?
Yes No Orthopedic (bone-joint-skeletal) problems?
Yes No Hemophilia, anemia or blood disorder?
2. Yes No Is your child presently under a physician’s care for a medical problem?
3. Yes No Is your child presently taking any medication?
4. Yes No Do you know of any reason why your child should not participate in sports?
Parent or Guardian Signature: _____________________ Date:________________
Check# ________ Amount $_______ Date ____________ Received by __________
League Fee: $ 30.00 per student or $50.00 for two students. Please pay by check, No Refunds
* No one will be excluded from playing for financial reasons. Questions should be directed to Ryan
Klinedinst, League President (536-5704)
* Please pay by check payable to: Prairie Football League, Inc.
* Payments are due Registration Day. A receipt must be presented to pick up your equipment.
(Please Print)
Player’s Name: Age: Grade, this fall __________
Parent’s Name: ________________________________________________________________
Address: ____________________________________________________________________
School: _____________________________________________________________________
Date of Birth: / / Telephone Number: ( )_____________________________
Please provide the following information about the player. It will be helpful in selections of teams and
issuing equipment. Did you play in the P.F.L. last year? Yes No What position? _________
Height: ______ Weight: ______ T-shirt size: (circle one) Adult size S M L XL XXL
Is the player covered by medical insurance: Yes No
Insurance Company Name: ___________________________ Policy # _______________________
No 4th, 5th, or 6th grader who has turned 13 years of age prior to August 1, and/or weighs more than
225 lbs. is eligible to play in the League.
If you have more than one child participation in the League, would you prefer they play on the same team?
Yes No Names of Children: _______________________________________________
Assistants are needed for each team. Interested individuals should note below if they would be willing
to help this season.
Assistant Coaching ___________ Reffing/Sidelines _____________ PFL Board Member ___________
Name _____________________________________________ Phone _________________________
Prairie Football League Incorporated
Waiver
I give my consent for to participate in the Prairie Football League,
recognizing that the League is a contact football league open to 4th, 5th, and 6th grade youths who have
not reached their 13th birthday by August 1, and who weigh less than 225 lbs. I have reviewed and I
am familiar with the Prairie Football League rules.
I am aware that football is a collision sport creating a risk that my child will be injured as a result of
his participation in the League. On behalf of my child and myself, I hereby release, waive and indemnify
the Prairie Football League, Inc., its Board of Directors, its coaches, its participants, Fairfield Community
School Corporation and any staff, coach or employee of the Fairfield Community School Corporation from
any liability resulting from any injury or illness incurred by my child during his participation in the League.
I am further aware that the League does not carry any medical insurance to cover any injury or illness that
my child may suffer. I have medical insurance that will cover my child in the event of injury or illness, or
I agree that I will pay all medical expenses resulting from any injury or illness that my child may suffer
while he participates in the Prairie Football League, indemnifying the League against any such expense.
I authorize the personnel of the Prairie Football League, Inc., to act for me according to their best
judgment in an emergency requiring medical attention.
___________________________________ ______________
Parent or Guardian Date
Waiver and Release Roster
I, the undersigned player, acknowledge, agree and understand that:
1. Voluntarily and of my own free will, I elect to participate as a member of the football team and league
indicated below.
2. I understand that there are certain risks and hazards involved in participating in football that may result
in injury or death to me or other players, including but not limited to those hazards associated with weather
conditions
3. I understand that the very nature of the game of football is hazardous and risky, including, but not limited
to, the acts of blocking, tackling, passing and catching of the ball, running, jumping, stretching, sliding, diving,
and collisions with other players and with stationary objects, all of which can cause serious injury or death to
me and to other players.
Further, I the undersigned player, agree that in consideration for the right to play as member of the league
designated below and in consideration for permission to play on the field arranged by the team or league:
1. I voluntarily elect to accept and assume all risks of injury incurred or suffered by me (a) while practicing or
playing as a member of the league so designated, (b) while serving in a non-playing capacity as a team member
during practice or play by other teams or by other players on my team, and (c) while on or upon the premises of
any and all of the courts arranged for by my team or league for practice or play.
2. I release, discharge and agree not to sue the league designated below, the field owner or other entity designated
below, for any claim, damages, costs or cause of action which I have or may in the future have as a result of injuries
or damages sustained or incurred by me from whatever cause including but not limited to the negligence, breach of
contract of wrongful conduct of the parties hereby released.
I acknowledge that I have read and understand each and every one of the provisions in this waiver and release
form, and agree to abide by them.
Prairie Football League, Inc. Fairfield Community Schools
Name of League Field Owner
______________________________ _____________________________ __________________________________
Name of Player Street Address City, State, Zip
___________________________________________ ________________
Parent or Legal Guardian Signature Date
Medical History Form
Players Name: ____________________________________________________
This form will constitute a medical history for our information. A complete physical exam by your family
physician is advised if you feel it is necessary. Please circle the appropriate answer for the following questions.
Please explain further on a “yes” answers.
1. Has your child ever shown any indication toward:
Yes No Being a diabetic?
Yes No Any type of seizures?
Yes No Any chronic disease or health problem?
Yes No Liver, spleen or kidney problems?
Yes No Heart or circulatory problems?
Yes No Respiratory problems?
Yes No Allergies?
Yes No Vision or hearing problems?
Yes No Hernia or genitalia problems?
Yes No Orthopedic (bone-joint-skeletal) problems?
Yes No Hemophilia, anemia or blood disorder?
2. Yes No Is your child presently under a physician’s care for a medical problem?
3. Yes No Is your child presently taking any medication?
4. Yes No Do you know of any reason why your child should not participate in sports?
Parent or Guardian Signature: _____________________ Date:________________
