2017FOOTBALL AND CHEERLEADING REGISTRATION
DIVISION / Ages as of August 1, 2017
Peewee / Ages 5, 6, 7
Freshman / Ages 8-9
JV / Ages 10-11
Varsity / Ages 12-13; 14-year-old contact Ray Gomolka FB Commissioner 913-6010
Participant Information
Child’s first name / Child’s last Name
Date of birth / Name of School as of Sept. 2017 / Football Player Weight
Address Information
Street address / Home Phone Number
City / State / Postal zip code
Parent’s /Guardian’s Information
Mother’s/Guardian’s name / Email address / Phone number
Father’s/Guardian’s name / Email address / Phone number
Emergency Contact 1 if PARENT/GUARDIAN is NOT available.(must be someone other than parent/guardian)
First name / Last name
Primary phone number / Relationship to Child
PHOTO RELEASE: I give permission for my minor child (as registered on this form) to be photographed/videotaped while participating with Boston Patriots Football and Cheerleading organization. I hereby grant permission that his/her image may be published in the end of season yearbook, local publication and/or Boston Patriots and OATKA websites.
ACKNOWLEDGEMENT: By signing below, I acknowledge that all information provided is correct and true. I also received a copy of and understand the Medical Auth/Medical Release, Parent Disclaimer, the Code of Ethics and Conduct and will abide by the rules within.
SIGN: ______DATE: ______
Emergency Medical Authorization/Medical Release
In the event the need arises to provide unforeseen or emergency treatment to my son/daughter, I understand that every effort will be made to contact me or the emergency contact person listed, however in the event that neither I, nor the emergency contact person can't be contacted, I hereby authorize and give permission to the coaching staff and board of directors of the Boston Patriots, as well as the authorization of emergency medical treatment by any licensed physician or dentist and to transport the child to any reasonably accessible hospital facility,
I know of no reasons why my child should not participate in Boston Patriots activities
PLEASE READ:
The parent/guardian of the child named on this online registration, release and agree to hold the Boston Patriots Little League Football Team and OATKA
Southern Tier Junior Football & Cheerleading, harmless of any loss, claim or damage as a result of their participation in the football and
cheer program.
We certify that this child is covered by a policy of insurance, which will pay for any medical expenses in the event of any injury, and we understand that the "Boston Patriots" insurance acts as a secondary to our own policy.
We agree to return or pay the current replacement cost for all Football and Cheerleading equipment issued by and belonging to the Boston Patriots Football & Cheerleading organization that is lost, damaged or not returned. All equipment must be returned cleaned.
We understand that our child is required to participate in fund-raising activities for this organization.
We understand that the Boston Patriots Football & Cheer organization is a volunteer run Little League and that each parent is expected to volunteer two times to help in the achievement of each child and the success and continuation of this organization.
We understand that all fees are NON-REFUNDABLE. A $30.00 Bank fee charged for returned checks! We understand that our child must be fully
registered, including all required forms and registration fees paid, before active participation is allowed with their team.
No child will be allowed to participate if she/he is missing a major organ such as eye, kidney, lung etc unless agreed upon in writing from parents,
doctor, coach and Boston Patriots Football &Cheerleading Board of Directors.
**BY WAY OF THIS ONLINE REGISTRATION AND ACCEPTANCE OF THIS WAIVER BELOW, I ACKNOWLEDGE THAT ALL INFORMATION GIVEN IN THIS REGISTRATION FORM IS TRUE, AND I HAVE READ/
UNDERSTAND ALL THE FOLLOWING: THE BOSTON CODE OF ETHICS FOR PARENTS/COACHES/CHILDREN AND AGREE TO ABIDE BY THE RULES
WITHIN, FURTHER PLAYER/CHEERLEADER SIGNATURE BELOW, ACKNOWLEDGES THEY HAVE READ THE CODE OF ETHICS AND AGREE TO
ABIDE, THE MEDICAL HISTORY/RELEASE FORM, THE EMERGENCY AUTHORIZATION AND THE AMATEUR WAIVER AND RELEASE OF LIABILITY.
BOSTON PATRIOTS MISSION STATEMENT
The mission statement of the Boston Patriots Little League Football and Cheerleading Association is to provide a safe environment where children can participate and learn the game of football and cheerleading. Our goal is to create a positive experience that reflects true sportsmanship, teamwork, strength of character, discipline and dedication. We will teach, encourage and promote the ideals of fair play, respect and proper values. The Patriots are committed to attracting quality volunteers who will help in the development of the youth for whom the organization was created. Our goal is to ensure that everyone associated with the Boston Patriots will be positive role models for our youth both on and off the field.
BOSTON PRINCIPLES:
Build self-esteem in young players,
Operate as a mission driven organization,
Succeed in having a respected organization within the local community,
Teach the skills required to develop strength of character,
Outreach to the community fostering the spirit of service in our youth,
Nurture sportsmanship leading to class, dignity and respect for the organization.
The Code of Ethics is a list of objectives that must be met to have a successful program. We hold each participant to these codes. By participating in the program, you agree to abide by the Code of Ethics and understand that by not doing so, will result in the following disciplinary actions or the possibility of having immediate loss of participation in all Boston Patriots sponsored programs for the remainder of the season.
The following are the disciplinary actions:
First time infraction, you will receive a verbal warning from your coach and will be responsible for apologizing to your team. Second time infraction, you will receive a verbal warning and you will sit out at the next game you attend, and apologize to your team.
Third time infraction, your coach and the Patriots Commissioner will meet with you and your parents and at that time further actions will be discussed.
Code of Ethics for Parents/Coaches/Children: I hereby pledge to provide positive support, care and encouragement for my children participating in youth sports by following this 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 events. I will place the emotional and physical well-being of my child ahead of any personal desire to win. I will insist that my child play in a safe and healthy environment. I will provide support for coaches and officials working with my child to provide positive, enjoyable experience for all. I will demand a drug-free, alcohol-free and tobacco-free sports environment for my child and agree to assist by refraining from their use at all youth sports events. I will remember that the game is for the children and not for the adults. I will do my very best to make youth sports fun for my child. I will ask my child to treat other players, coaches, fans, and officials with respect regardless of race, sex, creed and ability. I will promise to help my child enjoy the youth sports experience within my personal constraints by assisting with coaching, being a respectful fan, providing transportation or whatever I am capable of doing. I will require that my child's coach be trained in the responsibilities of being a youth sports coach and that the coach agrees to the youth sports coaches' code of ethics. I will read the NYSCA National Standards for youth sports and de everything in my power to assist all youth sports organizations to implement and enforce them.
Football & Cheerleader Code of Conduct: I will attend all practices, games, meetings and any other team/squad function on time. I will show respect toward ALL coaches, football players, cheerleaders and referees at all times. I will demonstrate good sportsmanship on and off the field during practice and games. I will not bully, use foul language, or argue with other football players, cheerleaders or coaches. I will be ready to learn and have fun on time. I will be a team and always put the team/squad first. I will obey the coaches and the rules of the Boston Patriots Football and Cheerleading team
Amateur Athletic Waiver and Release of Liability
READ BEFORE ACKNOWLEDGING:
In consideration of being allowed to participate in any way within the BOSTON PATRIOTS FOOTBALL & CHEERLEADING program, related events and activities, the undersigned acknowledges, appreciates and agrees that:
I understand and recognize that football is an aggressive physical sport and that contact between players is intrinsic to the nature of the game. In playing the game of football there is a risk of injury, up to and including loss of life, and while particular rules, equipment, and personal discipline may reduce this risk, the risk does exist; and, 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 my participation; and, I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any behavior or condition which I regard as unusual or posing a significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS; BOSTON PATRIOTS FOOTBALL & CHEERLEADING INC, Program, their officers/board members, officials, agents, coaches and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damaged to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.
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.
This is to certify that I, as parent/guardian with legal responsibility for this participant, have read and understand the Waiver and Release of Liability for THE PLAYER/CHEERLEADER LISTED ON THIS REGISTRATION FORM.
which has been acknowledged by my child and do consent and agree to his/her release as provided above of all the Releases, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releases from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.
Boston REGISTRAR USE ONLY
Date of Birth / Age / Jersey Number / Documentation
Birth Certificate
Medical / Recent Photo
Waivers
NO REFUNDS AFTERJULY 31, 2017
ALL PAPERWORK MUST BE IN FOR CHILD’S NAME TO BE PLACED ON ROSTER – NO EXCEPTIONS.
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