Premission to Participete:
- PERMISSION TO PARTICIPATE I acknowledge that I am fully aware of the potential dangers of participation in any sport
and I fully understand that participation in football, cheerleading, dance and/or step may result in SERIOUS INJURIES,
PARALYSIS, PERMANANET DISABILITY AND/OR DEATH. Furthermore, I fully acknowledge and understand that
protective equipment does not prevent all participant injuries. I, the parent/guardian of the above-named participant, do
hereby give my approval for my child/ward to participate, and further assert that I have verified with my child/wards
physician, and in my opinion, my child/ward is physically fit and can participate without limitation in any and all Local,
Regional, National, League/Conference, Association and team/squad activities, including transportation to and from the
activities by a licensed driver.
- SCHOLASTIC FITNESS
I am of the opinion that my son/daughter/ward is scholastically fit and would benefit by participation in this program. I
agree to submit a copy of my son/daughter/ ward's last completed grade, end of year/last complete report card or a
written statement of scholastic fitness from the school administration.
- We acknowledge, AND WE understand the risks involved in my CHILD/WARD, my playing FOOTBALL, which is a
collision sport; the NOCSAE committee has adopted the following warning to be read by, and signed by, both the
parent/guardian and participant. DO NOT USE THIS HELMET TO BUTT, RAM OR SPEAR AN OPPOSING PLAYER,
THIS IS IN VIOLATION OF FOOTBALL RULES AND CAN RESULT IN SEVERE HEAD, BRAIN OR NECK INJURY,
PARALYSIS OR DEATH AND POSSIBLE INJURY TO YOUR OPPONENT, THERE IS A RISK THAT THESE
INJURIES MAY ALSO OCCUR AS A RESULT OF AN ACCIDENTAL CONTACT WITHOUT INTENT TO BUTT, RAM
OR SPEAR, NO HELMET CAN PREVENT ALL SUCH INJURIES.
- EQUIPMENT UNIFORM RESPONSIBILITY Parent/Guardian Initial: Player Initial:
I assume full responsibility for any and all equipment/uniforms loaned to my child/ward and I agree to promptly return,
upon request, the uniform and other equipment in as good condition as when received except for normal wear and tear.
If I fail to adhere to this policy, I will be responsible for and promptly pay the replacement cost of such equipment.
CODE OF CONDUCT The Ideology Of Youth Sports Including This Program Is To Promote Good Understanding And Fundamental Knowledge Of The
Sport. It Is Also Critical That Good Sportsmanship Including The Ability To Always Conduct Oneself In An Appropriate Manner Of
Positive Accord Both On And Off The Field. It Is Understood That Any Incident Considered Detrimental To The Pursuit Of This
Ideology Will Not Be Tolerated. It Will Be Addressed In Accordance With The Statutes Of The Association, Conference, Current
National Affiliation, State and Local Laws, And May Result In Dismissal From The Program And The Inability To Participate In
Any Future Related Activities Of The Association. This Code Of Conduct Applies To All Involved With The Program Including But
Not Limited To, The Football Players, Cheerleaders, Spirit Participants, Parents And Guardians.
I the athlete, have chosen to participate in an a sport where injuries may occur
and I do understand that it is my responsibility to report all of my injuries and illnesses or suspected injuries
and illnesses to the organization’s staff, including but not limited to: coaches, team physicians, and athletic
training staff. I further understand and recognize that my health and safety is the most important thing and
without disclosing all injuries and or illnesses, it can not be properly determined if you are in the physical
condition necessary to participate. I understand that I must provide a full and accurate medical history
including any symptoms, health complaints and any prior injuries and/or disabilities I have experienced
before, during or after athletic activities.
By signing below, I acknowledge:
● My organization has provided me with specific educational materials including the CDC Concussion fact sheet
(http://www.cdc.gov/concussion) on what a concussion is and has given me an opportunity to ask questions.
● I ACKNOWLEDGE THAT I HAVE READ THE FACT SHEET on the CDC website for Parents and Players.
● I have fully disclosed to the staff any prior medical conditions and will also disclose any future conditions.
● There is a possibility that participation in my sport may result in a head injury and/or concussion. In rare
cases, these concussions can cause permanent brain damage, and even death.
● A concussion is a brain injury, which I am responsible for reporting to the team physician, athletic trainer,
coach, parent volunteer, or official.
● A concussion can affect my ability to perform everyday activities, and affect my reaction time, balance, sleep,
and classroom performance.
● Some of the symptoms of concussion may be noticed right away while other symptoms can show up hours or
days after the injury.
● If I suspect a teammate has a concussion, I am responsible for reporting the injury to the staff.
● I will not return to play in a game or practice if I have received a blow to the head or body that results in
concussion related symptoms.
● I will not return to play in a game or practice until my symptoms have resolved AND I have written clearance
to do so by a qualified healthcare professional.
● Following concussion the brain needs time to heal and you are much more likely to have a repeat concussion
or further damage if you return to play before your symptoms resolve.
Based on the incidence of concussion as published by the CDC football and cheer, among other sports, have
been identified as high risk for concussion.
I represent and certify that I and my parent/guardian have read the entirety of this document and fully
understand the contents, consequences and implications of signing this document and agree to be bound
by this document.