Building Character, Leadership, and Athletic Excellence
Organization Address: 4200 NW 16TH STREET SUITE 219, LAUDERHILL FL. 33313
Phone: 1-888-280-6470
Email: [email protected]
Website: www.thelyfehousefoundation.org
Tax-Exempt/Nonprofit Status: 501(c)(3) Organization (PENDING)
Program Season/Year: 2026-2027
Participant Full Name: _________________________________________
Date of Birth: ____ / ____ / ______
Age: _______
Gender: ______________________
School: _________________________________________________
Grade: _______
Sport/Program: __________________________________________
T-Shirt Size: ☐ YXS ☐ YS ☐ YM ☐ YL ☐ YXL ☐ AS ☐ AM ☐ AL ☐ AXL
Parent/Guardian Name: _______________________________________
Relationship to Participant: _________________________________
Address: _________________________________________________
City: __________________ State: ______ Zip: ________________
Primary Phone: ____________________________________________
Secondary Phone: __________________________________________
Email Address: ____________________________________________
Emergency Contact Name: _____________________________________
Relationship: _____________________________________________
Phone Number: ____________________________________________
Alternate Phone: __________________________________________
Primary Physician: _________________________________________
Physician Phone: __________________________________________
Medical Conditions/Allergies: _______________________________
Current Medications: ______________________________________
Insurance Provider: _______________________________________
Policy Number: ___________________________________________
Participants and parents/guardians agree to:
☐ Demonstrate respect toward coaches, officials, teammates, and spectators.
☐ Maintain good sportsmanship at all times.
☐ Follow all program rules and safety guidelines.
☐ Refrain from bullying, harassment, or inappropriate behavior.
☐ Support a positive and inclusive environment.
Failure to comply may result in disciplinary action, including suspension or removal from the program.
I authorize THE LYFE HOUSE FOUNDATION to photograph, record, and use images or videos of my child for program-related publications, social media, promotional materials, and community outreach efforts.
☐ YES, I grant permission.
☐ NO, I do not grant permission.
I understand that participation in athletic activities involves inherent risks, including but not limited to falls, collisions, injuries, illness, and other unforeseen events.
By signing below, I voluntarily assume all risks associated with participation and release, waive, discharge, and hold harmless THE LYFE HOUSE FOUNDATION, its officers, directors, coaches, volunteers, sponsors, and affiliates from any claims, liabilities, damages, costs, or expenses arising from participation in program activities.
I certify that my child is physically capable of participating and authorize emergency medical treatment if necessary.
Registration Fee: $________________
Scholarship Requested: ☐ Yes ☐ No
Amount Paid: $________________
Balance Due: $________________
Payment Method: ☐ Cash ☐ Check ☐ Credit/Debit Card ☐ Other
I certify that all information provided on this form is accurate and complete. I have read and understand all program policies, waivers, and agreements contained in this registration packet.
Parent/Guardian Name (Print):
Signature:
Date: ____ / ____ / ______
Registration Received By: _____________________________________
Date Received: ____ / ____ / ______
Payment Received: $________________
Participant ID Number: _______________________________________
Notes: