Read SSYFCA_registration_form_2012 text version

Sebastian Sharks Youth Football & Cheerleading Association Application 2012 BC: ____

Information (PLEASE PRINT) You must also provide a copy of the birth certificate and a recent wallet size picture PIC: ____ PIF: ____

Child Name: Last __________________ First _____________________ Date of Birth __/__/__ Weight (Tackle) _____ Age as of August 1st _____ Participating in? (Circle one) Football Shirt size (youth/adult) s m l xl Cheer Shorts size (youth/adult) s m l xl N Flag Y N

Returning Participant Y

Mailing Address: Street ___________________________ City ______________________ Zip Code _____________ Mother's Information: Name Last _____________________ First _____________________ Email: ____________________________________________________ Phone H ______________ W _______________ C ______________ Father's Information: Name Last _____________________ First ______________________ Email: _____________________________________________________ Phone H_______________ W _______________ C _______________ Emergency Contact: Name Last ______________________ First _____________________ Relationship: _________ Phone H _______________ W ________________ C _______________ Medical conditions we should be aware of: _____________________________________________________________ Allergies: _________________________________________________________________________________________ Volunteer Hours Please be advised that you are expected to and will be assigned to volunteer. The team parent or team parent coordinator will ask you to choose or will assign you volunteer activities. Anyone failing to comply will be required to pay an additional $50 to cover the cost of manning the activity. The league reserves the right to withhold pictures or trophies if the volunteer time is not done or the fees are not paid. Name (individual completing form) _____________________ Signature ________________________ Date __/__/__ Registration Fees If paid in full in one lump sum payment before July 1st: Tackle or Cheer (other than flag) $125 Flag Cheer $60 Flag Football $60 Payment plan, or after July 1st: Tackle or Cheer other than flag $150 Flag Cheer $80 Flag Football $80 There is a $5 reduction in fee for each additional child in a family. There are a limited number of scholarships available for those who qualify. Please see a member of the SSYFCA board to request an application if you wish to apply. A payment plan is available, but early payment discounts do not apply. Please see any member of the SSYFCA board for details. Returned Check Policy

There will be a $35.00 charge for any returned check. There are NO refunds, NO exceptions, unless the league cannot field a team. In that case, the league will refund the fee minus $25 for administrative costs. Financial Assistance Program I would like to donate $__________ to the SSYFCA financial assistance program to help underprivileged children with their registration fees. 1

Refund Rules

SSYFCA Code of Conduct Agreement

(Please initial next to each statement and sign at bottom)

_____The parent(s)/guardian(s) of the above named participant do hereby understand and agree that a strict code of

conduct will be enforced. This includes, but is not limited to, any foul language, negative comments, physical contact of an aggressive nature, alcohol use, questioning coaching or referee decisions, or any action deemed distracting or unsportsmanlike. Any such behavior observed by the Coach and/or Board Member will result in a written warning and, if necessary, the immediate removal of the offending individual. This code of conduct extends to any individual attending a league event/practice, including, but not limited to, participants, parents, guardians, or spectators. Upon second offense, the person will be removed permanently from all league activities for a time to be determined by the Board of Directors. Refusal to leave will result in the removal of the offender's child until the problem is resolved to the Boards' satisfaction. _____The parent(s)/guardian(s) of the above named participant do hereby give approval for participation and understand all inherent risks and hazards associated with this activity. _____I/we hereby absolve, indemnify, and hold harmless the Sebastian Sharks Youth Football and Cheerleading Association (SSYFCA) and its' board of directors, its organizers, sponsors, and volunteer staff for any injury that may occur to my/our child. I/we are aware that SSYFCA does not provide trained medical professionals at any league activity. _____I/we understand that transportation to and from any activity is my/our sole responsibility. _____I/we understand that no refunds will be given for any reason once payment has been made. _____I/we acknowledge and understand that any check written to SSYFCA returned for insufficient funds will not be redeposited, but will be returned to you and a cash payment plus a $35 returned check fee will be required. _____I/we acknowledge that families will be assigned to work as a volunteer for concession, field set up, chain management, or cleanup for no less than 4 hours per season. Positions and times will be assigned by the SSYFCA if not chosen by the family. If the family wishes to be excused from this requirement, a fee of $50 can be paid to the league. I/ we further acknowledge that it is my/our responsibility to cover the assignment and if I/we cannot, it is my/our responsibility to find a replacement and inform the appropriate league representative. _____I/we acknowledge that each child will have to participate in fundraisers as a team, league, and individual to raise funds for the support of the SSYFCA. This will include a candy fundraiser and any other fundraising activities approved by the board. The league reserves the right to restrict playing time or withhold trophies and pictures if fundraising is not performed or funds from fundraising activities are not turned into the league. Failure to turn in funds from fundraising activities constitutes theft by conversion. _____I/we are aware and acknowledge that the SSYFCA is not responsible for my/our child before, during or after any league activity. There must be a parent or guardian present at all times. If an emergency arises, the child must leave with the parent or guardian. _____I/we acknowledge the responsibility for all SSYFCA issued equipment/uniforms for the purpose of any league activity. Custom altering is not permitted and will result in a replacement charge at current costs. All equipment/uniforms are to be returned upon request. Failure to do so may result in prosecution, legal proceeding or report to collection agencies. The league reserves the right to withhold trophies or pictures until such time as the equipment is returned.

Name: _________________________________ Signature: ______________________________ Date ___/___/____


SSYFCA 2012 Minor Medical Release Form

CHILD'S NAME: __________________________________________________________________________ PARENT/GUARDIAN NAME: _______________________________________________________________ HOME PHONE: ____________________ CELL: _________________ WORK: ________________________ EMERGENCY CONTACT NAME: _____________________________ PHONE: ______________________ Does your child have accidental/hospitalization insurance? ______ Primary Insurance Information: Company: ____________ Policy Number: ___________Group Number: ___________ Plan Number: ________ Child's Primary Physician: _______________________________ Phone: ______________________________ Please answer the following questions: 1. Has your child undergone any surgery in the past 12 months? Yes No If yes, Please explain: _______________________ ____________________________________ 2. Does your child take medications on a daily basis? Yes No If yes, please list the medications: __________________________ _____________________________________ 3. Does your child have asthma? Yes No use an inhaler? Yes No 4. Please list any and all allergies your child has: _____________________________ Does your child have any physical limitations that the SSYFCA should be aware of? If so, please describe: ______ _________________________________


As the parent or legal guardian of ___________________, I hereby authorize and give my consent for any medical emergency treatment or denial of treatment for my son/daughter/ward (listed above) should it be deemed necessary by a qualified medical doctor or dentist. In the event I cannot be reached, I give the authorized Sebastian Sharks Youth Football and Cheerleading Association, INC, coach and/or activity supervisor the authorization to act on my behalf should a medical or dental emergency arise while participating in the Sharks activity or event. I consent for my child/ward to participate in the Sebastian Sharks Football and cheerleading program/activity/event. I declare that my child/ward is physically fit and has the skill level required to participate in this program. I, as the parent/legal guardian of the above listed youth, do hereby assume all risk and hazards incidental to the conduct of this activity (which may include, among other things, muscle injury and broken bones) and on my behalf of my child/ward, on behalf of my child's/ward's heirs, executors and administrators release and forever discharge the released parties defined below of all liabilities, claims, actions, damages, costs or expenses, including, but not limited to, attorney's feeds and disbursements. For this program the released parties are the Sebastian Sharks Youth Football and Cheerleading Associations, Inc., the City of Sebastian, The Sebastian Police Department and the officers, directors, employees, coaches, agents, representatives, volunteers, successors and assigns of each of the foregoing entities. As parent/guardian of the above child/ward, I expressly acknowledge that we release the Sebastian Sharks Football and Cheerleading Associations, Inc. and any co-sponsoring agency from all liability whether for negligence, action, or inaction for any injury, loss or damage connected in any way whatsoever to participation in Sebastian Sharks Youth activities (which may include, but is not limited to, games, practices, and transportation to and from events) whether on or off Sebastian Sharks premises. The undersigned acknowledges that participation in the activity may involve risk of contact between participants, effects of the weather , and other risk conditions associated with the sport/activity/event. I further grant the released parties the right to photograph and/or videotape my child/ward and to use these photos and media materials as well as my child/ward's name, face, likeness, voice and appearance in connections with newsletters, publicity, advertising, promotional and Internet materials without reservations, compensations or limitation. The released parties are, however, under no obligation to exercise said rights herein granted. I, as the parent/legal guardian for the above listed youth, attest that I am at l east 18 years of age and eligible to enter into a binding agreement.


Parent/Legal Guardian Name: (Print Clearly) ______________________________________________________________________________ Parent/Legal Guardian Signature: ________________________________________________________________________________________

Child's Name: __________________________________________________________________________ A copy of this form will be released to the Head Coach of your child's team only. The original will be kept on file with the SSYFCA.

By my signature below, I hereby swear and attest that all information provided on this application is true and complete to the fullest extent of my knowledge. I fully understand that as a Parent of and a participant of the SSYFCA, verbal or physical abuse will not be tolerated. I am also aware SSYFCA has Zero Tolerance for the use or distribution of drugs and alcohol during SSYFCA practices, games (home and away). My child and I will conduct ourselves accordingly and abide by the SSYFCA rules and regulations. I have received a copy of the rules and regulations pertaining to my child's involvement, and I agree to all the rules and guidelines as set forth by the SSYFCA. As a condition of participating, I fully understand that as a parent, it is my responsibility to have my child at each practice and game on time. If a child is to miss a practice or game, prior notice should be made, if at all possible, to the Head Coach or the SSYFCA office. I also understand that it is my obligation to contribute to the league volunteer hours throughout the season. Failure to fulfill my volunteer obligations can result in my child not participating and/or practicing until the obligation is fulfilled. I also understand that unsportsmanlike conduct will not be tolerated and violators will be removed at the time of the incident and not allowed to return until appropriate punishment can be handed down by the SSYFCA Board of Directors.

Signature of Parent/Guardian: _____________________________________ Date: _________________

Signature of Parent/Guardian: _____________________________________ Date: _________________ ---------------------------------------------------------------------------------------------------------------------------------------

Payment Plan

I understand that if I am participating in the payment plan option, I must have my registration fees paid in full by Oct 1, 2012, or my child will not be permitted to participate from that date until fees are paid in full.

Parent Signature: _________________________________________ Date: ____________________________ Payment History: Amt of Payment Form of pmt Paid by Received by Date





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