2901 Milam Street Suite #200, Shreveport, LA, 71103 Phone: 972-998-3198 Website: www.ShreveportNFLFootball.com Parent / Guardian 1 First Name:Last Name: Home Phone: Mobile Phone/Provider: Email: Address: City:State:Zip Code: Relationship to Player: Volunteer: (Leave blank if you do not wish to volunteer at this time) ! Head Coach ! Assistant Coach Parent / Guardian 2 First Name:Last Name: Home Phone: Mobile Phone/Provider: Email: Address: City:State:Zip Code: Relationship to Player: Volunteer: (Leave blank if you do not wish to volunteer at this time) ! Head Coach ! Assistant Coach NFL Flag Waiver:NFL FLAG requires all participants to complete the NFL FLAG Player Participation Agreement Form online. Upon completion of the form, the participant will receive secondary medical insurance coverage as well as a USA Football Player/Parent membership.

Please Note: You will need to select the state of LA and Caddo Parish/Shreveport NFL Flag on the form. If your league is not listed in the dropdown menu please contact your local organization concerning the NFL FLAG waiver form. Please visit www.NFLFlag.com/Form/Player for NFL FLAG Player Participation Agreement Form. Once you have completed the NFL FLAG Player Participation Agreement, please confirm by checking the box below and continue with the registration process. ! YesI have completed the NFL FLAG Player Participation Agreement Form online. ! NoI have NOT completed the NFL FLAG Player Participation Agreement Form online. Patient Signature: Date Signed: Player Information First Name:Last Name: Home Phone: Mobile Phone/Provider: Email: Address: City:State:Zip Code: Desired Name on Jersey: Birthdate (mm/dd/yyyy) _________________ Please Circle Gender: Male / Female Comments / Special Requests School Information School: ____________________________________________ Grade: ________________________________ Emergency Contact & Medical Information Emergency Contact Name: ____________________________________________ Emergency Contact Phone: ___________________________ Insurance Provider: ____________________________________________________ Insurance ID: ________________________________ Insurance Provider Phone: _______________________ Doctor Name: ________________________________________________ Doctor Phone: _____________________________ Allergies / Special Needs Concussion Information: Caddo Parish / Shreveport NFL Flag requires that all families read and acknowledge the Concussion Compliance Information. Please visit http://usafootball.com/health-safety/concussion-awareness to read and print this information. Once read, please confirm that you have read the information as required below. ! Concussion Agreement (required) Registration Fee: $85/per player Deadline: August 24th, 2015 Fee includes jersey, flags and 10 games plus playoff. NOTE: Add an additional $10 for LATE REGISTRATION. Checks payable to Shreveport NFL FLAG