Parent/Guardian must watch online Concussion Video AND Infomed Concent form must be signed by Parent /Guardian and Participant

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1 NEW (Staple copy of Birth Certificate to back of original form) TRANSFER (Attach signed release form) Transfer from: RETURNEE PLAYER - CHEERLEADER 20 TAMPA BAY YOUTH FOOTBALL LEAGUE INC. REGISTRATION FORM Team/Organization Name: Player Date of Birth Player 7/31 Cheerleader Date of Birth Cheerleader 9/1 Division: Mighty Mite/Flag Pee Wee Super Midget Midget Varsity Please print legibly on this form PARTICIPANT INFORMATION: LAST NAME FIRST NAME Childs Nickname ADDRESS EMERGENCY PHONE # CITY ZIP Parent/Guardian must watch online Concussion Video AND Infomed Concent form must be signed by Parent /Guardian and Participant PARENT/GUARDIAN INFORMATION: GUARDIAN #1 LAST NAME FIRST NAME ADDRESS CITY ZIP (If different than child) CONTACT PHONE # ADDRESS RELATIONSHIP TO CHILD GUARDIAN #2 LAST NAME FIRST NAME ADDRESS CITY ZIP (If different than child) CONTACT PHONE# ADDRESS RELATIONSHIP TO CHILD FAMILY MEDICAL INSURANCE: Do you have primary insurance coverage for above child? YES NO Medical Conditions: Allergies: (list all allergies) IMAGE RELEASE In consideration of the minor child/ward indicated above, being allowed to participate in any way in the TBYFL Football/Cheerleading Program, related to events and activities, the undersigned agrees that such participants likeness may be photographed or videotaped and that such image may be published in an outlet used to promote or publicize the sports program. I HAVE READ & AGREE TO ABIDE BY THE TERMS OUTLINED ABOVE AND ON THE REVERSE SIDE OF THIS FORM Signature Witnessed By Guardian - Signature Date Guardian - Print Name Date 3901 George Rd. Tampa, FL Info@TBYFL.com Mail: P.O. Box Tampa Fl 33622

2 TAMPA BAY YOUTH FOOTBALL LEAGUE INC. PLAYER/CHEERLEADER REGISTRATION FORM AND PARENT/GUARDIAN AGREEMENT ************************************************************************************************************************************************* I/We understand my signature on the front side of this registration form indicates I have read and I/we are in agreement with the following statements: I/We the parents(guardians) of the named child do hereby give my/our consent to his/her participation in any and all of the activities during our (TBYFL) current season. I/We do assume all the risks and hazards incidental to the conduct of the activities, and transportation to and from activities. I/We likewise release from responsibility any person transporting my/our son/daughter to or from activities. I/We do, further release, absolve, indemnify and hold harmless the Tampa Bay Youth Football League, organizers, sponsors or supervisors appointed by TBYFL. It has been explained to me and I/we understand that football and cheerleading are dangerous sports, and injuries from participation in these activities can be serious. I /We hereby consent to any and all medical treatment which may be deemed necessary by the attending physicians. It is my intent to grant authority to administer and perform all examinations, treatment and diagnostic procedures, which may be deemed advisable and necessary during the course of my child's care. In case of injury during a practice or game, the boy/girl will receive first-aid attention. The team sponsor or coach will not be held responsible for any medical attention, which might be required. TBYFL assumes no liability for what happens when it comes to the events of football/cheerleading due to any unforeseen accident or death, the parents/family have waived their legal rights. A limited Athletic Benefit Insurance Policy will be provided for the each participant. Such insurance coverage is intended to supplement your present homeowners' and/or hospitalization insurance. I/We understand the TBYFL Insurance Fee is non-refundable. This fee is payable before my/our son/daughter is allowed to start practice. It has been explained to me and I understand that if my child becomes injured at school or during a football/cheerleading practice or game, a medical release must be provided before resuming participation with any athletic team with TBYFL. I/We further agree to return all uniforms and equipment issued to our son/daughter at such time as his/her sponsor or coach may request, and to pay the cost of repair/replacement of said equipment in the event of damage/loss. Equipment not returned will be grounds for not releasing my son/daughter to another organization. I/We understand that under TBYFL rules Pee Wee players are required to play a minimum of 8 plays and all other squads are to play a minimum of 5 plays. I/We understand that any player or cheerleader initiating or participating in a verbal or physical altercation is subject to removal from any and all TBYFL participation, and can override roster decisions of any individual organization. I/We acknowledge that we are required to access or request a copy from the Organization my/our child is registered with, the Rules and Regulations of the Tampa Bay Youth Football League (website address I/We acknowledge that we have read the Rules and Regulations of the Tampa Bay Youth Football League and understand the rules regarding Birth Certificates and/or verification of date of birth. The information provided about my child's name, date of birth, age, address, school information and photo is correct. I authorize TBYFL to request official school records that verify information is correct and that my child is in good standing and eligible to participate in youth football/cheerleading. I/We further understand misrepresenting my/our son/daughter or their age could result in forfeiture of all games by his/her team, suspension and/or criminal prosecution. My child will abide by the rules of the Tampa Bay Youth Football League. PARENTS CODE OF ETHICS I will encourage good sportsmanship by demonstrating positive support for all players, coaches and officials at every game, practice or other youth sports event. I will place the emotional and physical well being of my child ahead of my personal desire to win. I will support the coaches and officials working with my child, in order to encourage a positive and enjoyable experience for all. I will remember that the game is for the players/cheerleaders - not for adults. I will do my best to make youth sports fun for my child. I will help my child enjoy the sports experience by doing whatever I can, such as being a respectful fan or assisting coaches. I will expect my child to treat other players, coaches, fans and officials with respect regardless of race, sex, creed or ability. I will not interfere with the team policies and behave as a fan supporting his/her team. I will not initiate or participat in any fights or arguments with the coaches, referees, or the opposing team understand that in doing so could result being trespassed from any and all TBYFL events. I will support good sportsmanship and fair play George Rd. Tampa, FL Info@TBYFL.com Mail: P.O. Box Tampa Fl 33622

3 2013 Town and Country Packers Parental Responsibility Agreement PARENT'S NAME(S): CONTACT PHONE(S): CONTACT (S): Most Packer communications will be via , please be sure to provide a functioning address. We will never share your info with anyone outside of the TBYFL organization. Please list all children in the Packer organization from your immediate family. CHILD(REN) NAME(S) SQUAD REFUND POLICY If you quit* before July 1, 2013 your refund will be 100% of what you've paid to date, minus the non-refundable $50 fee If you quit* between July 1, 2013 and July 30, 2013 your refund will be 50% of what you have paid to date minus the non-refundable $50 fee. If you quit* on or after July 30, 2013 There is no refund. (*The date you return all of the equipment and/or uniform(s) is the quit date that the refund will take effect according to the refund policy above.) PARENTAL RESPONSIBILITY AGREEMENT please initial each box stating that you agree with the terms listed: I understand that my player/cheerleader will not be issued equipment/uniforms, or be allowed to begin practice until ALL FEES ARE PAID IN FULL OR A PAYMENT AGREEMENT HAS BEEN SIGNED. I understand that if any equipment/uniforms due back to the Packers are not returned, I am responsible for the replacement value of the missing items (approx. $250.00) I understand that if any of my checks are returned due to insufficient funds or any other reason, a MIN.FEE OF $25.00 will be added to my balance due PLUS ANY OTHER FEES INCURRED. I understand that if my child quits, for whatever reason, before the end of the season (including post season) my child will NOT receive a trophy. I understand that it is my obligation to participate in one mandatory fund raiser this year. Details will be announced at the beginning of the season. I understand that each squad will take weekly turns volunteering in the Packer concession stand and it is my obligation to volunteer to work at least one shift for each child I have enrolled during the assigned week(s) for my child's squad. VOLUNTEER RESPONSIBILITY AGREEMENT As a member of the Tampa Bay Youth Football League, the Packers organization is required to work the Skyway concession stand one day per season. At least one family member from each family (18 years or older) is required to work a shift. please select one I WILL VOLUNTEER : I agree to work at least one shift (three hours) on the Packers designated Concession stand day at Skyway. I WILL NOT VOLUNTEER: I understand that if I fail to complete my agreed upon hours or if I choose to opt out this will result in a $75.00 fee. This payment is due FIVE (5) days after the date of Concession. I understand my child will be ineligible to participate until this fee is paid As a non-profit VOLUNTEER organization the Packers are dependant on our families not only for payment of equipment/uniforms that we provide but also for assistance in achieving the goals of the organization. At a minimum we expect at least one family member (16 years or older) from each family to volunteer for Packer concession duty during their squad's assigned week and for Skyway concession duty on our assigned day. In addition, we always need help in order to provide all of our children and family members with the best experience possible. If you would like to further assist the organization you may volunteer on the committee(s) of your choice (below). If you are interested, please select a committee below and you will be contacted by the committee chairperson in order to coordinate service hours. This is also a great opportunity for high school students or anyone else in need of satisfying service hours. pick at least one: Field Operations - assists with daily field maintenance and clean up Yearbook Committee - takes pictures at games and practices and assists in yearbook creation Sponsorship Committee - works with board members to find corporate sponsors Homecoming Committee - helps to plan, setup and cleanup the homecoming game and dance Board Member at large - helps the board as needed and attends board meetings I have read, understand and will adhere to all of the statements above. My signature below is my acceptance of this agreement for all of the children listed above. SIGNED: DATE:

4 Town and Country Packers Florida Statute : Theft by Conversion A person commits theft by conversion, when having lawfully obtained funds or other property of another under an agreement or other known legal obligation to make a specific application of such funds of specific disposition of property, he knowingly converts the funds or property to his own use in violation of such agreement or legal obligation. This section applies notwithstanding monies paid to TNC Packers for rental of said property for participant use during the Football/ Cheerleading season. I,, have read and thoroughly understand the implication of Theft by Conversion. I further understand that upon completion of the season, withdrawal from the TNC Packers or at the request of the TNC Packers, I must and will return all of TNC Packers issued items, equipment, and supplies within 10 days. I further understand that failure to comply with this agreement is just cause for the TNC Packers to file criminal charges against me, in order to facilitate recovery of said equipment or charges. The following equipment is for TNC Packers use only and it will remain the property of the TNC Packers. Furthermore, all the equipment issued to me is in good condition and will be returned in the same condition. Any necessary repairs or replacement due to neglect, loss, or misuse will be my responsibility. Please Check One: Football Cheerleading Helmet $85.00 Game Uniform $ Shoulder Pads $65.00 Comp. Turtle Neck $75.00 Game Pants $65.00 Practice Pants $25.00 Childs Name: Please Print Full Name Parent s Name: Please Print Full Name Parent s DL Number: Parent s Signature Date Witness Date

5 Department of Parks, Recreation and Conservation Hillsborough County, Florida YOUTH SPORTS PARTICIPATION MEDICAL RELEASE FORM Please read carefully and sign either Part I or Part II PART I The undersigned, as parent or legal guardian of (print name of name) hereby consents to the following in the event (print name of name) is injured during his or her participation in youth sports: Agents or officials of the youth organization in which (print name of name) participates may administer first aid or arrange for transportation to a medical facility if the agent or official deems there to be an emergency. At that time medical treatment may be given to (print name of name) included but not limited to anesthesia and emergency surgical treatment as deemed necessary by a qualified physician at the medical facility. No action shall be taken until attempt is made to contact me at the phone number(s)listed below Home Phone: Work Phone: Cell Phone: Parent or Guardian Parent or Guardian Name: Parent or Guardian Parent or Guardian Name Signature: (STATE OF FLORIDA) The foregoing instrument was acknowledge be me on this day of, 200 (COUNTY OF HILLSBOROUGH) known to me or who has produced Drivers License # (did) or (did not) make an oath. (name of parent/guardian) who is personally as identification and who PART II The undersigned, as parent or legal guardian of (print name of name), I do not desire to sign the medical and release form above. Parent or Guardian Parent or Guardian Name Parent or Guardian Parent or Guardian Signature PLEASE NOTE: If Part I is not signed, the child will not be allowed to participate

6 DEPARTMENT OF PARKS, RECREATION AND CONSERVATION Hillsborough County, Florida INFORMED CONSENT/GENERAL RELEASE - YOUTH SPORTS PARTICIPANTS This is a release of liability. Please read carefully before signing. Since participation in youth sports activities can be dangerous, Hillsborough County requires all participants (and their adult parent(s) or guardians) to assume all risks associated with youth sports b signing this general release. For and in consideration of my child being permitted to participate in HILLSBOROUGH COUNTY youth sports activities, I hereby voluntarily release, discharge, waive and relinquish any and all claims or actions for damages for personal injury, permanent disability, death, or property damage which I or my child may have, or which may hereafter accrue to me or my child, as a result of my participation in youth sports activities during play and while I am at the facility while others play or for any other reason. This release is intended to discharge, in advance, HILLSBOROUGH COUNTY, its officers, employees and agents, the Tampa Bay Youth Football League, its officers and agents, and the owners and maintainers of any facility used for the activities, from any and all liability arising out of or connect in any way with my child's participation in sports camp/clinic activities, even though that liability may arise out of negligence or carelessness on the part of HILLSBOROUGH COUNTY, its officers, agents or employees and the Tampa Bay Youth Football League, its officers and agents. I further understand that serious accidents occasionally occur during youth sports activities, and that participants occasionally sustain serious personal injuries, death or property damage as a consequence thereof. Knowing the risks, I have voluntarily applied for my child to participate in the activity and thereby agree to assume those risks to release and hold harmless HILLSBOROUGH COUNTY, its officers, agents or employees and the, Tampa Bay Youth Football League, its officers and agents used for the activity who (through negligence or carelessness) might otherwise be liable to me or to my child (or my heirs or assigns) for damages. I further understand and agree that this release, discharge, waiver, and assumption of risk is to be binding on my and my child's heirs, executors, administrators and assigns. I further agree to indemnify and to hold harmless HILLSBOROUGH COUNTY, its officers,, agents or employees and the Tampa Bay Youth Football League, its officers and agents for any loss, liability, damage, cost or expense which they may incur as a result of any injury or property damage I or my child may sustain while participating in the activity. I agree to comply with the program's stated and customary terms and conditions for participation according to the Tampa Bay Youth Football League. If I observe any significant changes with regard to my child' readiness for participation in the program, I will remove my child from the program immediately. I have read this Informed Consent/General Release, fully understand its terms, that I give up substantial rights by signing it, and sign it voluntarily. Parents Signature: Date : Address: This document is a release of liability which affects the rights of your child. Please read the document carefully before signing. I have read this Informed Consent/General Release and I understand the seriousness of the risks and accept them as a participant. (To be signed by all players who are league age 12 and older) City: Name of Participant: Participant Signature: Date of Birth: Date Signed:

7 Tampa Bay Youth Football League Informed Consent about Concussions and Head Injuries Effective July 1st, 2012 Florida Statute requires the parent or guardian and the youth who is participating in athletic competition or who is a candidate for an athletic team to sign and return an informed consent that explains the nature and risk of concussion and head injury, each year before participating in athletic competition or engaging in any practice, tryout, workout, or other physical activity associated with the youth s candidacy for an athletic team. The Facts: A concussion is a brain injury. All concussions are serious. Concussions can occur without the loss of consciousness. Concussions can occur in any sport. Recognition and proper management of concussions when they first occur caan help prevent further injury or even death. What is a concussion? A concussion is an injury that changes how the cells in the brain normally work. a concussion is caused by a blow to the headd or body which causes the brain to move rapidly inside the skull. Even a Ding, Getting your bell rung, or what seems like a mild bump or blow to the head can be serious. Concussions can also result from a fal or players colliding with each other or obstacles, such as a goal post, even if they do not directly hit their head. To help recognize a concussion, you should watch for the following signs in your athletes: 1. A forceful blow to the head or body that results in rapid movement of the head. -and- 2. any change in the athlete s behavior, thinking, or physical functioning. Signs and symptoms of concussion that may be reported by a coach or other observer: appears dazed or stunned. Is confused about assignment or position. Forgets sports plays. Is unsure of game, score, or opponent. Moves clumsily. answers questions slowly. Loses consciousness(even briefly) Can t recall events prior to hit or fall. Signs and symptoms that may be reported by the player: Headache or pressure in the head. Nausea or vomiting. Balance problems or dizziness. Double or blurry vision. Sensitivity to light. Sensitivity to noise. Feeling sluggish, hazy, foggy, or groggy. Concentration or memory problems. Confusion. Does not feel right. Both parents/guardians and players are advised to take the Center for Disease Control s free online concussion training at HeadsUpConcussion.html Under Florida law the player who is suspected of having a concussion or head injury must be removed from play or practice. Before the player may return to practice or competition a written medical clearance to return stating the athlete no longer exhibits signs, symptoms, or behaviors consistent with a concussion or other head injury must be received from an appropriate health care professional trained in the diagnosis, evaluation, and management of concussions. In Florida, an appropriate health care professional (AHCP) is defined as either licensed physician(md as per Chapter458, Florida Statutes) a licensed physicians assistant under the supervision of a MD/DO(as per Chapters and , Florida statutues)or a health care professional trained in the management of concussions. I have read and understand this consent form, and I volunteer to participate. Player Name: Signature: Date: As parent or guardian, I have read and understand this consent form and give permission for my child named above to participate. Parent/Legal Guardian Name: Signature: Date: