P.O. Box 10071 Napa, CA 94581 Thank you for registering your child as a Napa Raider. There are several required documents that must be properly completed before your child may participate at the first practice. We have set Saturday, July 24,2010 as the deadline for submitting all documents and payment of all fees. There is a $15 late fee for documents submitted and fees paid after this date. If your Medical Appt. is after this date, just let us know and we can make a note of this. You can mail your payments and documents to the PO Box above. 1. Napa Raiders Registration and Fee Information Form a. This is the document you filled out at the time of registration. There is information on both sides of this form and a signature is required on both sides. 2.
Player / Parent Contract Form a. This form is required by the Mountain Valley League. b. Official Player's Birth Certificate c. Each new Player must submit an original official Birth Certificate which includes the official stamp of the issuing authority. d. Players returning from the 2009 season have Birth Certificates on file with us already.
3. Medical Clearance Form a. This form must have Doctor's signature. b. This is the only form we will accept. c. Do not wait until later to begin requesting an appointment to have your Doctor sign this form. d. It may be several weeks before you can get an appointment and this may cause a delay in your child's participation. Your child can not participate until we have the Medical Clearance Form in our files. e. Emergency Medical Consent form, needs to be signed and dated. 4. Waiver of Liability and Image Release Forms a. These forms are required by AYF and must be signed and dated. 5. Report Cards a. Each Player must submit a complete and legible copy of the report card they will receive at the end of the school year in June of 2010. b. This copy must fit on one 8.5" x 11" letter sized paper without cutting off any information at all. c. We prefer that you bring the original report card to us and we will make the photo copy and return the original to you.
Complete and sign both sides.
Registration #_
Napa Raiders 2010 Participant Application Napa Raiders Aplicacion del participante 2010
Player 1: jugador(a)
Player 2: jugador(a)
cirst
Name as on Birth Cert.
Atom/we como opanca ea la acts de nactrnente
Initial
Birthdate
inicial
Fecha de nacimiento
Cheer
Football (Wgt) Peso
Yes - No Goes by this First Name
Goes by this Last Name
Played Last Year
09 - Squad
Lettaman per este primer nombre
Le llaman por este segundo oomftre
iuego el alto pasado
OB-Eguipo
First Name as on Birth Cert. Nomtri come aparece en le acta de nactmento
Last Name as on Birth Cert.
Initial
Birthdate
ApelHdocomoafwnceenlaxtadtnecimtnto
inicial
Fecha de nacimiento
Cheer
Football (Wgt) Peso
Yes - No Goes by this First Name
Goes by this Last Name Le llaman por este segundo nombre
Le llaman por este primer nombre
Player 3: jugador(a)
Last Name as on Birth Cert. AptHMo como operac* en Aa acta Oe nac/mento
First Name as on Birth Cert. NombrdcomoapareceenleactBdenaclmento
Played Last Year
09 - Squad
juego el ano pasado
OSEquipo
Last Name as on Birth Cert.
Initial
Birthdate
ApeUKfocomoapanceenlaactaaenaclmonto
inicial
Fecha de nacimiento
Cheer
Football (Wgt) Peso
Yes - No Goes by this First Name
Goes by this Last Name
Played Last Year
09 - Squad
Le llaman por este primer nombre
Le llaman por este segundo nombre
Juego el alto pasado
O&Equipo
Players live at this Street Address/ direction address: Jugador(a) vive en esta Home Phone direccion: Numero de tetefono
Cfty/Ciudad
Zip/codigo postal
Cell Phone or Emergency # Numero
Which Parent do these players live with
detetefonocelular o de emergencia
Con que padre vnen estos jugadores(as)
Last Name, First Name/ Apetitdo, Nombre
Street Address/tnrecci6n
City/Ciudad
Zip/cdd^oposte/
Father Padre Home Phone/ Numero cte telefono
Cell Phone W Numero detetefonocelular
Work or Emergency $/ Numero dÂť teUtono tie trabajo o emergencia
Occupation/ ocupacion
Email Address/ Dreccion de cotreo ekxirinica
Last Name, First Name/ Apenuo, Nombre
Street Address/ direction
City/Ciudad
Ziplcodigo postal
Mother Madre Home Phone/ Numero de telefono
Cell Phone W Numero dateWfonocelular
Work OT Emergency %/ Human* detelefonode trabajo o emergencia
Occupation/ ocupacion
Email Address/ Direccion de carreo electron**)
This registration form will not be processed until we have received your payment of $75.00 per player registration fee. Your signature below indicates you have read the fee schedule and the volunteer work obligation. Esta forma de registro no sera procesada hasta que hagamos recibido su pago de $75, 00 de registio por cada jugadorfa). Su firma abajo Indica que usted ha leido el horario de las fechas de pago y la obligation voluntaria de trabajo. Incomplete or illegible forms will be returned without processing. Las formas incompfetas o Hegibtes seran regresadas sin serproceso.
Date/ Fecha
Signature Of Parent or Guardian/ Firma del padre o del guarda TTj/s is a two page form and must be signed on each page. Esto es una forma de dos pd^nas y se debe firmar en cada pagiria.
P.O.Box 10071 - Napa, CA 94581 Page 1 of 2 pages.
Complete and sign both sides.
Complete and sign both sides.
Registration #_
Football Registration/ Registro Non-Refundable Deposit (per Playet) Uniform Use and Association Fees (per Player) Coteas/Mre/umdefu/ufbrmeycfefea&x&cMn Player AccessoriesMccesorfos deljuyador
There is a $1 5 penalty for fees and documents not submitted before SATURDAY, JULY 24. Players registering
$75
after SATURDAY, JULY 24 have 10 calendar days to submit all fees and documents or pay a $15 penalty. Hayunpenaltl de 915 pen tos oononrios y documentas no someOdos antes 24Jullo..
$200 Players who drop or quit on or after August 1 will forflt all fees paid. WO REFUNDS after August 1 . LosJugadoresenqulenesdeJaaoses»Jenenodespu^del1deagostoperder»»todoslosqueseapagado. Sohabar MNOUNOS REEMBOLSOS despues del 1 de agosto.
Home jersey with Player's name Yersey de practica TSame SocEs Calcetmes para fos parOdo
Total $275
Players who are injured while participating, and are unable to finish the season will receive a pro-rated refund of the Uniform Use and Association Fees upon wrtten application to the Board of Directors and per Board guidelines . Jugadoresi^selastim»nd&aifoqaeparlKipanynopuedcntenmn& u»dek»Unlforrnesydelaasocia<Mncompletandotmaaplicacl6n estofueadoptadoporla MesaDrtctivay par las regies tie la Mesa.
Cheer Registration/ Registro Non-Refundable Deposit ^perPlayerJ DegOs/to Nofleembolsable_£xrjuqadct}. Association Fees per player (includes Regional competition fees] Cobras par de la
$75
$175
We offer payment plans and also take Visa and Master Cards.
»«
Contact Barbara Johns , Treasurer at 707-257-0373
Player AccessoriesMecesorfos deljugador ^^feSS incliudes shoes, liner, briefs, socks, bows, back pack and warm up suit
PLEASE PRINT NAME AND ADDRESS OF PERSON RESPONSIBLE FOR PAYMENT:
Total $400 C^cO
There is a $25 discount on the Association Fees for each additional family member. Hay un descvento de K5 en tos cobras ete la asociacttn para cada miemtro ttticionaldelafomtBa.
NAME: ADDRESS
ALL PAYMENTS AND REGISTRATION FORMS INCLUDING: PLAYERS & PARENTS CONTRACT, MEDICAL CONSENT, MEDICAL RELEASE, CODE OF CONDUCT, COPY OF JUNE, 2010 REPORT CARD, COPY OF BIRTH CERTIFICATE (IF NOT A RETURNING PLAYER) AND VOLUNTEER FORMS MUST BE RECEIVED PRIOR TO THE FIRST DAY OF PRACTICE, ANY DELAY CAN BE CAUSE FOR YOUR CHILD NOT TO BE ALLOWED TO PRATICE.
tx^qMtMMteMdbx^enfemfeef/mrato
Date/ Fecha
Signature of Parent or Guardian/ Firma del padre o del guarda This is a two page fom) and must be signed on each page. Esto es una forma de dos pftginas y se debe fimnar en cada pigina.
Page 2 of 2 pages.
P.O.Box 10071 - Napa, CA 94581 www.napanigJithawkSvOFg
Complete and sign both sides.
AMERICAN YOUTH FOOTBALL Waiver and Release of Liability - Minor ASSOCIATION NAME - ftfflPft READ BEFORE SIGNING
IN CONSIDERATION OF , my child/ward, being allowed to participate in any way in American Youth Football, lnc.(AYF) or American Youth Cheer dba, Regional/National Championships, my Local AYF Affiliations), athletic sports program, related events and activities, the undersigned acknowledges, appreciates, and agrees that: 1) The risk of injury to my child/ward, myself, from the activities involved in these programs is significant, including the potential for permanent disability, paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2) FOR MYSELF, SPOUSE, AND CHILD/WARD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for child/ward, participation; and, 3) I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant concern in my child/wards', readiness or, hazard during my presence or participation, and/or in the program itself, I will remove my, child/ward, from participation and bring such to the attention of the nearest official immediately; and, 4) I, for myself, my spouse, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS American Youth Football, lnc.(AYF), American Youth Cheer dba, my Local AYF Affiliation, their officers, directors, officials, volunteers, agents, and/or employees, other participants, sponsoring agencies, tournament host, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event ("RELEASEES"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, incident to my child/wards', involvement or participation in these programs,WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, TO THE FULLEST EXTENT PERMITTED BY LAW. 5) I, for myself, my spouse, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my child/ward's involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Print Name of Parent/Guardian:
Parent/Guardian Signature:
Date Signed:
UNDERSTANDING OF RISK I understand the seriousness of the risks involved in participating in this program, my personal responsibilities for adhering to rules and regulation, and accept them as a participant.
Print Participants Name:
Participant's Signature:
Date Signed:
NOTE: This form as with any and all forms used by your Association should be reviewed by your local counsel for compliance with any state or local statutes. This form should be kept on file for a minimum of 7 years, longer in the event of an injury. Please confer with your local attorney for advice as to the appropriate maintenance and storage term for this and all such forms.
AMERICAN YOUTH FOOTBALL Medical Clearance Form ASSOCIATION NAME Medical Clearance Form - Must be dated after January 1st of the Current Season
I, hereby my signature below, do certify that I am licensed by the state and am qualified in determining that: {Childs Name:) is physically fit and I have found no medical or observable conditions which would centra-indicate him/her from participating in youth flag football, tackle football, cheer, dance or athletic activities. I am therefore clearing this individual for athletic participation. Please Print -or- Use Office Stamp Here:
Signature:
Print Name Clearly:
Date: f Must be dated after January 1st, of the Current Season )
Office Address:
PLEASE NOTE: If this Medical Clearance is voided by injury, accident, or illness, it will be the responsibility of the Parent/Legal Guardian to notify the participants Coach and League Officials, ft will also be the responsibility of the Parent / Legal Guardian to obtain WRITTEN permission from his/her physician to resume participation. A "Doctors Resume Participation Medical Clearance Form" is available from the league or you may have the doctor supply his/her own WRITTEN Clearance as long as it is on the doctor's official stationary and includes the following statement: "(Participants Name) is physically fit and I have found no medical or observable conditions which would contra-indicate him/her from participating in youth flag football, tackle football, cheer, dance or athletic activities. I am therefore clearing this individual for athletic participation." This statement must be supplied by the physician attending to the injury, accident, or illness. This form can be modified of substituted ONLY to comply with local and/or state laws or due to medical practitioner regulations.
Emergency Medical Treatment, Consent and Information The following information will be used in the event that a parent / legal guardian is not available. The purpose of this information is to provide a quick reference for medical personnel should the need arise. Please fill out this form completely, if a particular question is not applicable write "none", n/a, or other appropriate comment otherwise none wiii be assumed. If additional space is needed, please use the back of this form. All information disclosed here will be treated as confidential. It will be the responsibility of the parent/legal guardian to notify the participants coach and league/event officials if any information needs to be added, deleted, changed, or updated in any way. ATHLETE INFORMATION
Phone: ( ) State: | Zip:
Nick Name: City:
Athlete's Name: Address:
PARENT OR GUARDIAN INFORMATION
Father's Name: Address: Hm Phone: ( ) Employer
City: Daytime Phone: (
)
| Email:
Mother's Name: Address: Hm Phone: ( ) Employer.
I City: Daytime Phone: ( )
| Email:
Guardian's Name: Address: Hm Phone: ( ) Employer:
City: Daytime Phone: (
;
)_
State:
| Zip:
State:
| Zip:
State:
1 Zip:
Email:
FAMILY MEDICAL INSURANCE
Policy #: Policy Holder Name: Family Physician's Name: Dr's Address: Phone: ( )
\:
Group: Group #:
|Fax:(
iCity: )
State:
| Zip:
] Email:
EMERGENCY MEDICAL INFORMATION
Preferred Hosprtal(s): Phone: ( ) Relationship: EMERGENCY CONTACT: Please list any medical conditions (allergies, asthma, etc.) And medications being taken by the participant named above. Please list any other information you may deem relevant, and helpful to emergency medical personnel: (please note if no information is given and the words "none" or "n/a" is not filled in then, "none" will be assumed. Allergies: Medical Conditions: Other Hereby my signature grant permission for my child/ward to participate in any and all, (Association name) and, American Youth Football, Inc / American Youth Cheer dba, program(s) sanctioned event(s), be they official or un official, including but not limited to, athletic, social and/or fundraising activities. I further hereby consent to any and all health care providers, authorize any first aid, emergency treatment, including but not limited to transportation to and from health care facilities and/or any medical professional to provide treatment, order injections, hospitalize, give anesthesia or perform surgery. I understand that this authorization is given prior to any need for medical care, but given to avoid unnecessary delay in emergency treatment which the attendant and/or medical professional may deem advisable in the exercise of best judgment I presume a reasonable attempt was made to contact me. "Print Parent/Legal Guardian Name *Signature Parent/Legal Guardian *Date The original Emergency Medical Treatment, Consent and Information form should travel with the coach and a copy should be kept at the administrative office of the sports organization. Due to privacy concerns, completed forms should be stored in a secure location with access restricted to those on a need to know basis for the purpose of medical care.
AMERICAN YOUTH FOOTBALL Image Release - MINOR ASSOCIATION NAME -Uflfb READ BEFORE SIGNING
my minor In consideration of (insert child's name)_ child/ward being allowed to participate in any way, in the American Youth Football, Inc. (HAYP) (dba American Youth Football and American Youth Cheer,) national championships and any other official AYF events and activities, the undersigned agrees that American Youth Football inc., is hereby granted the unrestricted and exclusive right and permission, free from approval or review, to copyright and/or use my child's/ward's likeness in ail media now or hereafter known, including but not limited to, pictures and videos of my child which he/she may be included intact or in part for promotion or other commercial use.
Print Name of Parent/Guardian: Parent/Guardian Signature:
Date Signed:
MOUNTAIN VALLEY YOUTH FOOTBALL PLAYER/PARENT CONTRACT TO BE COMPLETED, SIGNED AND SUBMITTED TO THE LOCATION ASSOCIATION
SECTION 1 - GENERAL INFORMATION (PRINT OR TYPE) Child's Full Name: â&#x20AC;&#x17E;___
Birthdate:
Child's Address:
,
Phone:
City/State/Zip:
Mailing Address: (If different from above)
School Attending this Fall:
.
Grade in Fall:
Parents Name: Emergency Contact: (Other than parent)
Name
Relationship
Medical Insurance Carrier:
Phone
ID #: (Furnish parents Social Security Number if No Insurance)
SECTION 2 - MEDICAL EXAMINATION fOR ATTACH PHYSICAL) Any known allergies or limitations:
While this examination may not constitute a complete medical examination, it does, on this date, based upon my observations, meet the requirements for the above named child to participate in organized tackle football or spiritleading (check one).
Remarks:
Physician's Name:
Physician's Signature:
Address:
Date:
Phone:
SECTION 3 - FINANCIAL RESPONSIBILITY AND PARENTAL/PARTICIPANT CONSENT
1. I/We as parent (s)/Guardian (s) of the above named child, have read, understand and agree to abide by the "Role of the Parent" and assume complete financial responsibility for MY/OUR child to participate in this program. 2. My/Our above named child has read, understand and agrees to abide by the "Players' Code of Conduct". 3. I/We, the parents(2)/guardian(s) of the above named child, do hereby give my/our approval for participation in the Mountain Valley Youth Football activities for the current season. I/We hereby waive, release, absolve, indemnify and agree to hold harmless, MVYF, the league, local team, organizations, managers, coaches, supervisors, participants, person providing transportation and any organizations this youth football program may be affiliated with. 4. In executing the foregoing release, I/We acknowledge that I/We understand that our personal medical/dental insurance will remain the primary carrier, and that insurance offered through this program is secondary in nature and is subject to an annual deductible set by the carrier. 5. I/We understand that any claims for injury arising out of My/Our child's participation must be reported to an association official within 30 days of injury. I/We understand the "Proof of Loss" must be completed in lull and filed within 60 days of receipt by us. I/We understand all monies, I/We paid to the team does not constitute payment of insurance coverage. I/We do indemnify MVL, the league, the association, and the insurance carrier should there be statements) by "anyone" that is in contradiction. I/We certify I/We read and understand the terms of the "Contract" and any "Disclosure" information required. 6. I/We hereby grant authority to a qualified doctor of medicine, physician, or qualified medical person (E.M.T., RN, LVN) to administer such medical treatment as deemed necessary under emergency circumstances.
Parent/Guardian Signature
Parent/Guardian Signature
Piayer/Spiritleader Signature