Step 1 of 333%Player Info* Please note that the information you provide will also be shared with our athletic therapists *Name* First Last Address* Street Address App. City State / Province / Region ZIP / Postal Code Email* Phone*Birthdate* DD slash MM slash YYYY Medicare card*New Player* Yes NoDid you play with another team last season?* No YesWhere did you play last season?*For Minor football (Tykes-Midget), if you played for Boucherville, St-Bruno, Laprairie or any team on the island of Montreal OR for Junior football, if you played with any other Junior team, Lasalle Warriors or North Shore Mustangs, do you have a release?* No Yes I did not play for any of these teamsWARNING! ***Without a release, you cannot attend any Packers organized activities***How did you hear about us?*ReferralFacebookInstagramLive nearbyEx-Packers playerOtherWho referred you?*Player name*Please specify*Level 2022* Cheerleaders $130.00 CAD Bantam (DOB: 2007-2008) $400.00 CAD Junior (DOB: 1998-2004) $450.00 CADEMERGENCY CONTACTName* First Last Relationship*Phone*Email* ALTERNATE EMERGENCY CONTACTName* First Last Relationship*Phone*Email* PLAYER MEDICAL INFORMATIONDo you have any allergies?* No YesPlease list all known allergies, including to tape and/or glue:*Do you have an Epi-Pen?* Yes NoDo you take any medication?* No YesList all medications, including for asthma*Do you wear glasses?* Yes NoDo you wear contact lenses?* Yes NoDo you have hearing problems?* Yes NoDo you have epilepsy?* Yes NoDo you have any learning disabilities or concentration problems (dyslexia, ADD, ADHD,etc)?* Yes NoDo you have asthma?* Yes NoDo you have diabetes?* Yes NoDo you suffer from cardiac or vascular problems?* Yes NoDo you have high blood pressure?* Yes NoDo you suffer from frequent fainting spells?* Yes NoHave you ever had a concussion?* No YesPlease identify the number of previous concussions*012345+When was your last one?* YYYY slash MM slash DD In relation to the most recent one, how long did the symptoms last?*Have you undergone any surgeries?* No YesList all surgeries you have undergone and the date they took place*Have you suffered any injuries in the past 2 years that required you to sit out of play for more than 1 week?* No YesList all injuries suffered in the past 2 years that required you to sit out of play for more than 1 week*Do have any other condition or disease not listed above?* No YesList all other known condition or disease*CommentsPaymentTotal Amount $ 0.00 CAD Payment Method* Credit/Debit Card (Online) E-transfer Interac Payment agreementSelect the number of payments required 1 2 3 4Payment 1* YYYY slash MM slash DD Payment 2* YYYY slash MM slash DD Payment 3* YYYY slash MM slash DD Payment 4* YYYY slash MM slash DD E-transfer steps to followSend to: vpadmin@gpkpackers.com Password to be used: Football Comment: include athleteβs name ***If these instructions are not followed, the e-transfer will be refused and the registration will be considered incomplete***Email used for Interac eTransfer:* Jumpstart confirmation # (if applicable)Credit/Debit Card (Online)*Card Details Cardholder NamePlease consent* I confirm that I am 14 years or olderPlease consent* I consent to medical information being shared with medical partners, when necessary for the management of injury/health conditionPolicy acknowledgement* I acknowledge the policies and my signature below indicates my consentBy signing below, you are authorizing the GREENFIELD PARK PACKERS Football Association to use photographs and/or video of you for the sole purpose of official GREENFIELD PARK PACKERS business (web site, newsletters, registration flyers, etc.). All photographs and/or video footage may only be taken during official GREENFIELD PARK PACKERS functions (practice, games, registration, etc.). ALSO, YOU ARE CONFIRMING THAT THE SUPPLIED INFORMATION IS CORRECT AND YOU UNDERSTAND THAT, SHOULD YOU BE UNABLE TO ANSWER QUESTIONS PERTAINING TO YOUR HEALTH, THE FIRST RESPONDER WILL RELY ON THE SUPPLIED INFORMATION TO ASSIST YOU WITH YOUR AILMENT. In such a case your consent to assistance will also be implied.Signature*Use you mouse to create your signature or put your initialsName of signee*
