Independent - Unity Youth Football Conference

Unity Youth Football Conference (UYFC)
Member of American Youth Football, Inc. on NFL Youth Partner
20___ Season Contract
0FOOTBALL
ASSOCIATION: 0UNITY VI KINGS
0UNITY SAINTS
UNITY YOUTH
[]CHEER/STEP/DANCE
0Independent
NO CANDIDATE WILL BE PERMITIED TO PARTICIPATE IN ANY ACTIVITY UNTIL THIS FORM HAS BEEN COMPLETED IN FULL.
NAME_____________________
DATE OF BIRTH _____ CURRENT AGE_ ___ AGE (ON Dec. 3
LAST
FIRST
ADDRESS ________________________________PHONE _________
STREET
CITY
ZIP
SCHOOL ______________ CURRENT GRADE _____
FALL GRADE AS OF (August) _____
1sr
) ___
**NOTIFY IN CASE OF EMERGENCY: ____________________
_ _ _
_ PHONE#
___________
_
FOOTBALL JERSEY SIZE_____ PANT SIZE.______
CHEER SKIRT SIZE_____ TOP ____ SHOE______
MEDICAL INSURANCE? YES_
NO__
NAME OF CARRIER________
POLICY#_________
SECTION I: Parents Authorization to Participate and Release Information/NO Refund Policy
I/We, the parent(s)/ guardian(s) of above named applicant to the UYFC, hereby give my/our approval to said applicant's participation in any and all UYFC activities
during the current season. I/We assume all risks and hazards incidental to such participation including transportation to and from the activities and do hereby waive,
release, absolve, indemnity and agree to hold harmless the local association and conference, the organizer, sponsors, supervisors, participants and any persons
transporting the applicant to and from activities, for any claim arising out of injury to said applicant. I/We agree to be financially responsible for Association/UYFC
equipment issued to the applicant other than the normal wear and breakage during games and practice and I/We will reimburse the Association/UYFC for the loss
and/or damage to said equipment. I/We give permission for UYFC, to verify participants school grades and certify that the above applicant is scholastically eligible to
participate. In consideration of my minor child/ ward being allowed to participate in any way in the UYFC program, related events and activities, I give my permission
that my child's likeness may be photographed or videotaped and that such image may be published in any outlet used to publicize Association, Conference or
National , Tackle and Cheer programs. I FULLY UNDERSTAND THAT THE UNITY YOUTH FOOTBALL CONFERENCE HAS A NO REFUND POLICY IN EFFECT.
Refunds will only be granted before the start of seasonal practice begins. A $45.00 administartive processing fee will be assessed for any refund requested before
seasonal practice.A letter must be submitted with the reasons for refund request.I/We understand that all files are property of UYFC executive office and may be
destroyed at the end of playing season ,only,by the direction of the Executive Director.
SECTION II: Insurance Statement
Each participant in the UYFC program must be covered by medical insurance in case of accident or injury during the current playing season. This conference does
underwrite the cost of medical insurance on a team basis for participants. The medical expense benefit of this plan is an "EXCESS" type benefit that picks up where
other coverage leaves off. If the parent/ guardian has an other Primary Coverage, whether individual, blanket or group coverage, which provides benefits or services
for, or by reason of, medical or dental care or treatment , then this plan, subject to the limits of the plan, will pay only the medical expenses not provided or
reimbursable under your coverage. If the parent/guardian has no Primary insurance coverage, then this plan, subject to the limitations and deductions of the plan will
provide insurance coverage.
SECTION Ill: Medical Examination/Emergency Medical Treatment Authorization
I/We the parent(s) /guardians(s) understand that our son/daughter must satisfactorily complete a physical examination and give our permission for any emergency
treatment necessary in the event of illness or injury to my/our child while participating in any scheduled UYFC, function including the supervised travel to and from
said function.
SECTION IV: Helmet Waiver (For Football Participants)
We acknowledge AND WE understand the risks involved in OUR CHILD playing FOOTBALL, WHICH is a collision sport: The NOCSAE committee has adopted the
following warning to be read by and signed by the parent/guardian. "DO NOT USE THIS HELMET TO BUTI, RAM OR SPEAR AN OPPOSING PLAYER. THIS IS IN
VIOLATION OF FOOTBALL RULES AND CAN RESULTS IN SEVERE HEAD, BRAIN OR NECK INJURY, PARALYSIS OR DEATH AND POSSIBLE INJURY TO YOUR OPPONENT.
THERE IS A RISK THAT THESES INJURIES MAY ALSO OCCUR AS A RESULT OF AN ACCIDENTAL CONTACT WITHOUT INTENT TO BUTI, RAM OR SPEAR. NO HELMET CAN
PREVENT ALL SUCH INJURIES."
**Parent /Guardian must initial here X _____
Participant must initial here X ____
I have read and understand the above statements in Sections I, II, Ill, and IV
------------------------�-------------------Date____
Print Name Of Parent /Guardian
Signature
Date_______
Notary Public Seal or Stamp (REQUIRED)
**OFFICE USE ONLY**
The undersigned certifies that all items on this contract were completed in full prior to this applicant's participation in any of team's activities.
Signature_______________________ TITLE________________ DATE_______
TO THE BEST OF MY KNOWLEDGE AND BELIEF I CERTIFY THAT THE ABOVE IN FORMATION IS TRUE.
EXECUTIVE SIGNATURE OF CERTIFYING OFFICIAL
OFFICIAL DATE