INDIAN RIVER COUNTY RECREATION DEPARTMENT

1800 27TH Street V ero Beach, FL

FOOTBALL REGISTRATION.----------__,

Player's Name: ---------------

Player's Home Address: ___________ _

Best# to Call ________________ _

~other's Info: _______________________________ _ NAME CELL#

Father's Info: --------------------------------NAME CELL#

Emergency Contact: -----------------------------NAME PHONE#

Insurance Company: ---------------------------­

Policy Number: ---------------------------------

Email Address: ----------------------------------

I would like to be a: ------NAME

__ Coach __ Team Sponsor

__ Assistant Coach Team Parent --

***REFUNDS WILL NOT BE GIVEN*** CREDIT WILL BE GIVEN TO APPLY TO NEXT

SESSION OF ACTVITY OR OTHER DEP ART~ENTAL ACTIVITY.

**I have read and fully understand the refund/credit policy __ _ Parent Initials

Please note: All county parks, ball fields and parking lots are SUBSTANCE FREE complexes. All alcohol, tobacco products and illegal substances are prohibited on the premises.

Date of Birth -------

Previous Team ----

__ Years of Exp.

Parents Please Initial: Returning ___ _ Draft

***************

OFFICE USE ONLY

Playing Age ___ _

Playing Weight __ _

He~ht _____ _

Registration Fee __ _

Birth Certificate ____ _

Flag Football ___ _

Junior Midget ___ _

Midgets-------

Juniors -------

DATE----- PARENT'S SIGNATURE----------

INDIAN RIVER COUNTY RECREATION DEPARTMENT

1800 27TH Street Vero Beach, FL

Consent to J\1edical Treatment of l\1inor

If the applicant is under 18 years of age, the parents or guardian must execute in addition to the mmor.

I hereby authorize any duly authorized physician, emergency medical technician, paramedic, nurse, hospital or other medical facility to treat myself or said minor for the purpose of attempting to treat or relieve any injuries received by myself or said minor while I or he was a participant or observer at the event named below.

I authorize any licensed physician to perform any procedure which he deems advisable if attempting to treat or relieve any injuries or any related unhealthy conditions of myself or said minor that he may encounter during any necessary operation.

I consent to the administration of anesthesia to myself and/or said minor as deemed advisable by any licensed physician.

I realize and appreciate that there is a possibility of complication and unforeseen consequences in any medical treatment and I assume any such risk on behalf of myself and said minor. I acknowledge that no warranty is being made as to the results of my treatment.

The undersigned parent and natural guardian or legal guardian of said minor does hereby represent that he is, in fact, in such capacity and agrees to save and hold harmless -and indemnify hi.diari River County, Florida, School District of Indian River County and their directors, officers, employees, volunteers, agents and representatives, event holders, event sponsors, event directors, event volunteers, physicians, emergency medical technicians, paramedics, nurses, hospitals or other medical facilities from all liability, lost, cost, claim or defect in lack of such capacity to so act and release said parties on behalf of the undersigned.

Event: ____________________________________________________ __

Name of Minor: ----------------~~--~--------------------------Print or Type

Name of Parents or Guardian: ----------------~----~-------------Print or Type

Address=------------------~~~-------------------------street

City: _________ _ State: ---- - Zip: ----------

Minor' s Signature: ---- --- - --------Date: _______ _

Parent's Signature: ---------------------------Date: _______ _

r

AUTHORIZATION TO USE PHOTOGRAPHIC, VIDEOTAPE, DIGITAL, ETC IMAGES

In consideration of Indian River County, Florida ("County") providing recreational services to my son, daughter or other child for whom I have legal responsibility, whose name is set forth below ("Child"), and otherwise.permitting my Child to participate in recreational programs provided by the County, I, on behalf of myself and my Child, hereby (1} authorize the County to create, use, exhibit, display, broadcast, distribute, and publish in any form of media (including, without limitation, print, television, internet, etc) (collectively "Publication"), pictures, images and depictions, including voice reproductions, of my Child or me (collectively "Images"), for use in connection with publicizing, displaying, promoting or explaining recreational services or programs provided by the County, (2} waive any rights (i) to confidentiality or privacy relating to the Images, (ii) to approve the Images prior to Publication, and (iii) to receive compensation for Publication of the Images, and (3} release. and discharge the County from any claims, causes of action or other form of liabilities arising out of or relating to the Publication of the Images, including any allegation that the County was negligent with respect to such Publication. The authorization, waiver and release set forth in (1}, (2} and (3} shall apply with equal force and effect in favor of and for the use and benefit of any other third party, person or entity playing any role in, or performing any act or omission in connection with or relating to, the Publication of the Images. For the purposes of this form, the terms "County," "third party" and "entity" shall include any elected commissioners or other officials, officers, shareholders, directors, employees and agents of such party. Unless expressly revoked in writing delivered to the County, this authorization shall continue in full force and effect for as long as my Child participates in recreational services or programs provided by the County.

Name of Child: ------------

Signature of Parent or other adult

having legal responsibility for Child----------~-----

Date: ______ _

Parents' Code of Ethics

I hereby pledge to provide positive support, care and encouragement for my child participating in youth sports by following this 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 insist that my chi I~ play in ·a safe and healthy environment.

• I will require that my child's coach be trained in the responsibilities of being a youth sports coach and that the coach upholds the Coaches' Code of Ethics.

• I will support coaches and officials working with my child, in order to encourage a positive and enjoyable experience for all.

• I will demand a sports environment for my child that is free from drugs, tobacco and alcohol and will refrain from their use at all sports events.

• I will remember that the game is for youth-not adults.

• I will do my very best to make youth sports fun for my chi ld.

• I will ask my child to treat other players , coaches, fans and officials with respect regardless of race, sex, creed or ability.

Date Parent' s Signature