1 Player Registration Packet

8/22/2019 1 Player Registration Packet

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Source:

SourceDate:

Player Name________________________________

Soccer Program

1-Year Player Registration Packet

Thank You for Registering!Signatures are required on the following pages:

Page 6 Page 7 Page 8 Page 9

Page 11


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Soccer Program Registration Form(Single Child)

Player 1 Information

FirstName: LastName:

StreetAddress: MailingAddress:

City: State: Zip:

HomePhone: CellPhone:

Tribe: School:

Age: MaleFemale DateofBirth://

TShirtSize:Youth:SMLXLAdult:SMLXLXXL

Parent/Guardian Information


StreetAddress:

City: State: Zip:

HomePhone: CellPhone:

EmailAddress:

EmergencyContact: Phone#:

Participant Agreement

Please review the next 3 pages and sign at the bottom of page 6 for theNB3F Soccer Program Participant Agreement

-Definition of Terms:

NB3F is a collective term to refer to the Notah Begay III Foundation and its affiliated organizationsincluding the SanFelipe Soccer Club,NotahBegay III SoccerLeague,USSoccer Foundation, and al

otherSanFelipeSoccerClub,NotahBegayIIIFoundation,USSoccerFoundation,andNotahBegayIII

SoccerLeagueassociatedofficers, coaches, employees,volunteers,agencies,oranyotherassociated

agent.

Participant(s)isdefinedasthoselistedonpage3underParticipant1Information


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Notah Begay III Foundation Soccer ProgramParticipant Agreement

Assumption of Risk, Waiver of Liability, and Indemnification Agreement

About Soccer and NB3F

Soccer is the worlds most popular sport, played by many players of all ages and levels. NB3F wishes to

promulgate this spirit of soccer in the safest manner possible. As such, NB3F would like to ensure alparticipants and participant family members are aware of the risks inherent to soccer. NB3F is dedicated to

providing the safest environment possible but some risks cannot be avoided without drastically altering the

game of soccer. Like all contact sports, soccer is an aggressive and physical game that carries some danger andpossibility of injury. We do not mean to frighten or discourage our participants, but simply increase theirawareness of these possible injuries so they may be fully informed.

Since minors do not have the ability to contract, we ask that you (the childs parent and/or guardian) sign

this Participant Agreement on behalf of yourself, your spouse, personal representatives, assigns, and the

participant(s).

Assumption of Inherent Risks It is impossible to foresee or list all of the risks inherent to the game of soccer but the following items may givethe participant(s) and his/her parent or guardian a better idea of the associated risk. Minor injuries such as

bumps, bruises, and soreness may occur, as soccer is an intense contact sport that includes several incidents of

physical contact. In addition, soccer requires a high amount of quick body transitions and so ligament, muscleand tendon tears are a possibility. On some occasions, more serious injuries such as concussions, broken bonesand cuts may occur. On rare occasions, major catastrophic injuries such as paralysis, stroke, heart attack, brain

injury, and death may occur. Soccer is also an outdoor sport that is often played in the hottest months of theyear, making heat stroke, heat exhaustion, and sunburns an associated risk. Accordingly, it is the duty of theparticipant or the participants parent/guardian to ensure proper hydration and application of sunscreen.

In accordance, I understand that soccer harbors inherent dangerous risks despite the best efforts of

NB3F and its staff to guard against them. I have read the previous paragraphs and understand: 1.) The

nature of soccer and its inherent risks 2.) The stresses of soccer in relation to its physical demands 3.) The

potential for minor, major, and catastrophic injury (including death). I hereby assert that the

participant(s)s participation in NB3F is entirely voluntary and that I understand all inherent risks.Waiver of Liability

In accordance with permission to participate in NB3F and at any other NB3F affiliated event, I, on behalf of theparticipant(s), my spouse, my heirs, personal representatives, or assigns do hereby release, waive, and discharge

NB3F, San Felipe Soccer Club, and the Notah Begay III Foundation (including its officers, coaches, employeesvolunteers, agencies or any other associated agent) from liability from any and all claims resulting from the

inherent risks of the activity of playing soccer or from the ordinary negligence of NB3F.

This agreement applies to 1) minor, major, or catastrophic injury (including death) from incidents or illnesses

that may arise during a NB3F associated event or on NB3F associated premises. These premises include but arenot limited to NB3F facilities and parking lots and San Felipe Pueblo premises. 2) any and all claims relevant to

damage to, loss of, or theft of property.Relevant Binding ClausesIndemnificationI agree to hold harmless, defend, and indemnify NB3F. (More precisely, defend and pay

any judgment and costs, including investigation costs and attorneys fees) from any and all claims of mine, mychild, my spouse, my family members, or my heirs arising from injury or loss due to participation in NB3F

(including those that arise from the risks inherent to playing soccer and the ordinary negligence of NB3F).

Cont.


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Relevant Binding Clauses (Cont.) Covenant Not to Sue I covenant not to sue NB3F for any present or future claim arising directly or indirectlyfrom my childs participation in NB3F. This includes claims resulting from inherent risks of playing soccer and

the ordinary negligence of NB3F.

Arbitration I agree to engage in good faith efforts to mediate any dispute that might arise between NB3F andme. Any agreement reached will be formalized by a written contractual agreement at that time. Should the issue

not be resolved by mediation, I agree that all disputes, controversies, or claims arising out of or relating to this

contract shall be submitted to binding arbitration in accordance with the applicable rules of the AmericanArbitration Association then in effect. I further recognize that the issue must be submitted to binding arbitrationin the State of New Mexico.

Venue and Jurisdiction Accordingly, I agree that if, in spite of this contract, action is brought against NB3Fregarding a claim, the appropriate trial court in the State of New Mexico has sole and exclusive jurisdiction and

that only the substantive laws of the State of New Mexico shall apply.

Severability I further expressly agree that the foregoing Assumption of Risk, Waiver of Liability, andIndemnification Agreement is intended to be as broad and inclusive as is permitted by the State of New Mexico

and if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full

force and effect.

Integration Clause I affirm that this agreement supersedes any and all previous oral or written promises or

agreements. I understand that this is the entire agreement between NB3F and me and cannot be modified orchanged in any way by representations or statements by any agent or employee of NB3F. This agreement may

only be amended by a written document duly executed by all parties.Acknowledgements, Assertions, and Agreements:

1. Health Status-I accept and assume full responsibility for consulting with a doctor about NB3F programs and events andhereby warrant, represent, and state that the participant(s) is in good physical condition and that the

participant(s) has no disability, impairment, or ailment that would prevent him/her from safely andcomfortably engaging in NB3F programs, events, or activities.

Furthermore, I assert that the participant(s):

Does not have epilepsy, heart disease, high blood pressure, sickle cell trait, or sickle cell anemia Has no other medical problems that would prevent him/her from safely and comfortably engaging in

NB3F programs, events, or activities

Possesses sufficient physical fitness and skill to enable safe participation in playing soccer2. Emergency Care- I authorize or agree:

NB3F to administer emergency first aid, CPR, and use of an AED when deemed necessary by NB3F orits affiliated officers

NB3F to secure emergency medical care or transportation (i.e. EMS) for the participant(s) when deemednecessary by NB3F or its affiliated officers.

NB3F to share my childs medical history with emergency medical personnel when deemed necessaryby NB3F or its officers.

To assume all costs of emergency medical care and transportation, including costs to my insurance co.


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Acknowledgements, Assertions, and Agreements (cont.)

3. Rules and Safety Equipment- I agree to instruct the participant(s) to: Review and carefully follow all of the NB3F guidelines, rules and procedures of safety and general

deportment while on NB3F and San Felipe Pueblo premises, whether or not the participant is engaged intraining events or activities at the time.

Immediately inform NB3F of any misconduct or dangerous situation during any NB3F related programor event

Wear required and appropriate equipment at all times while playing4. Further Agreements related to safety- I agree:

That NB3F will conduct activities in good faith and reserves the right to terminate the participant(s)sparticipation if the participant(s) is incapable of safely meeting the rigors of the activity

That NB3F reserves the right to terminate the participant(s)s participation if he/she disallows otherparticipants from safely or enjoyably participating.

5. Data CollectionI grant NB3F permission to collect basic health data, including height, weight, BMI and soccer performancestatistics from the participant(s) during the program for the sole purpose of program evaluation regarding the

effectiveness of the program on the overall health and wellness of program participants. I understand that theParticipant(s) health measurements will be kept confidential and that the participant(s) will remain anonymous

in any published data or program evaluation.

6. Media ReleaseI understand that photos and/or video may be taken of the participant(s) for NB3F promotional purposes. NB3F

has permission to take and use photos/video of the participant(s) for NB3F promotional purposesAcknowledgement of Understanding.

I have read this 3 page Participant Agreement- Assumption of Risk, Waiver of Liability, with relevant

binding clauses, and acknowledgments, assertions, and agreements, and fully understand its terms. I

understand that I am giving up substantial rights, including my right to sue NB3F for injuries or death

resulting from the inherent risks of playing soccer or the ordinary negligence of NB3F. I further

acknowledge that I am signing this agreement freely and voluntarily on behalf of the participant(s), and

intend my signature to be a complete unconditional release of all liability, including that resulting from

the inherent risks of the activity or from the ordinary negligence of NB3F, to the greatest extent allowed

by the state of New Mexico.

Signature

Printed Name of Participant:

Signature

Printed Name of Parent/Guardian:

Signature of Parent/Guardian: Date:


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Soccer Program Concussion Policy

What is a concussion?

A concussion is an injury that changes how the cells in the brain normally work, it is caused by a blow to the head

or body that causes the brain to move rapidly in the skull. Concussions can be caused by blows to the head,

hitting ones head on a hard surface, or even falls to the ground. All concussions are serious and can causeserious short term and potentially long-term side effects.

Why does the Notah Begay III Foundation Soccer Program (NB3FSP) care about concussions?

At the NB3FSP, we are dedicated to keeping each participant safe and healthy. We take head injuries very

seriously as recent finding have indicated the harmful short and long-term effects of concussions. In order to

keep each participant safe, we plan to take the upmost care in dealing with concussions.

What signs/ symptoms of a concussion will the NB3FSP will be watching out for?

-Signs observed by coaching staff:

Appears dazed or stunned Appears confused and is forgetful Is unsure of game, environment, or rules Moves clumsily Answers questions slowly Loses consciousness (even briefly) Shows behavior or personality changes Cant recall events prior to hit or fall Cant recall events after hit or fall

-Symptoms reported by the participant

Headache or pressure in 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

What will the NB3FSP do if a participant is suspected to have a concussion?

The NB3FSP will take the following steps in handling head injuries and suspected concussions:

1. The participant will be immediately removed from playa. If any of the above signs or symptoms are present or any head injury is suspected, the participantwill be taken out of play for their own safety

2. The NB3FSP will recommend the participant be immediately seen by a health care professionala. The NB3FSP does not have the capacity to diagnose or treat head injuriesb. Parents and/or emergency contacts will be notified and advised to see a health care professional

immediately.

3. The participant will only be allowed to return to play after they have been granted permission from ahealth care professional.

a. One of the greatest dangers in dealing with concussions is the event of a repeat concussionoccurring while the brain is still healing from the original concussion. Repeat concussions carry

the largest threat of serious long-term and even deadly consequences.

At the NB3FSP, our primary concern is each participants safety, especially when it comes to serious headinjuries. Please sign below, indicating you understand, acknowledge, and accept the guidelines and terms

set forth in this document.

Signature Printed Name of Participant:

Signature

Printed Name of Parent/Guardian

Signature of Parent/Guardian Date:


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Soccer Program Consent to Release

NB3F is a collective term to refer to the Notah Begay III Foundation and its affiliated organizations, including theSanFelipe

SoccerClub,NotahBegayIIISoccerLeague,USSoccerFoundation,andallotherSanFelipeSoccerClub,NotahBegayIII

Foundation,USSoccerFoundation,andNotahBegayIIISoccerLeagueassociatedofficers,coaches,employees,volunteers,agencies,oranyotherassociatedagent.

Consent to Release

I, _______________________________ the parent/legal guardian of the below listed child/children, givepermission for NB3F Staff to release my child/children to any of the following people listed below at NB3F

games, activities, and events.

Child 1: Child 3:

Child 2: Child 4:

Parties to be Released

Please list the people you consent to have your children released to:

1. Name: Relationship:Home Phone: Cell Phone: Work Phone:

Email:

2. Name: Relationship:

Home Phone: Cell Phone: Work Phone:

Email:



Email:



Email:

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

I am the parent or legal guardian of the above-named child/children and hereby consent to the release of saidchild/children to the above named party(s). I hereby acknowledge the terms set forth above and agree to assume

responsibility in accordance with those terms. Under penalty of perjury under the laws of the state of New

Mexico, I attest to the truthfulness, accuracy, and validity of the forgoing statement.

Signature

Parent/Guardian Printed Name: Date:

Signature

Parent/Guardian Signature: Date:


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Soccer Program Parent/ Legal Guardian Code of Conduct Agreement

It is the policy of the NB3F that its members shall conduct themselves in a sportsmanlike and positive manner when

representing themselvesat games, tournaments, practices, and otherrelated activities. Members are defined as

players, coaches, parents, guardians, and other NB3F supporters. As a parent/legal guardian of a child involved with

the NB3F, I agree to abide by and follow the rules and guidelines below:

1. I will promote the emotional and physical well being of the athletes ahead of my personal desire to win.2. I will remember that my child plays soccer for his/her enjoyment, not mine.3. I will encourage good sportsmanship through my actions by demonstrating positive support for all players.4. I will provide support for coaches and officials working with the athletes to provide a positive experience for

all.

5. I will demand that my athlete treat all players, coaches, officials, parents, and spectators with respectregardless of race, creed, color, sex, or ability.

6. I will treat all players, coaches, officials, parents, and spectators with dignity.7. I will not use improper language, poor attitude, behavior, or mannerisms.8. I will cheer for my child and his/her team and allow the coach to do his/her job of coaching.9. I understand that making physical contact with any coach, player, or official will result in expulsion from the

NB3F.

10.I will not taunt any player, coach, or official.11.I will abide with all rules & regulations of the Pueblo of San Felipe.12.No member of the NB3Fshall act in a way that brings discredit NB3F or the Pueblo of San Felipe.

We want our coaches to focus on the players, not parents. The players should enjoy their experience, especially on

game day, and not have adults interfere with their games in a negative manner.

I understand that by signing this document, I am agreeing to support and promote this parent/legal guardian code of

conduct agreement. Further, my failure to comply with this agreement or my participation in any defined conduct

subject to discipline will result in disciplinary action, up to and including expulsion from the NB3F games or other

NB3F Foundation Activities.

Signature

Name of NB3F Participant(s):

Signature

Parent/Legal Guardian Printed Name:

Parent/ Legal Guardian Signature: Date:


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Soccer Program Player Uniform NeedsNew Players Uniforms are $25 and include a NB3FSL t-shirt, Nike shorts, Nike

socks, and Nike Shin GuardsA $10 replacement fee applies for NB3FSL t-shirt

Player Information

Name: Season:

IstheParticipantnewtotheNotahBegayIIISoccerProgram?Yes No

Please place a check where soccer gear is needed and circle relevant sizes

NB3FSL Shirt Youth: S M L Adult: S M L XL

Nike Shorts Youth: S M L Adult: S M L XL

Nike Shin Gauds Youth: S M L Adult: S M L XL

Nike Socks S (13c-3y) M (3y-5y) L (6-8) XL (9-12)

If you are unsure about sizes, please call Clint Begay:

(505) 440-0409

[email protected]


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Soccer Program Participant General Medical History

THIS MEDICAL HISTORY FORM IS MEANT FOR

ONE INDIVIDUAL PARTICIPANT ONLYFor the safety of your children, please fill out a medical history form for each individual child.

Please fill out a second medical history form for your second child

Participant 1 Information


Age: DateofBirth:// Gender:MaleFemale

Emergency Contacts Information

ThisisthepersonyouwouldliketheNB3SoccerProgramtocontactincaseofanemergency

EmergencyContact#1: Relationship:

CellPhone: WorkPhone: HomePhone:

EmailAddress:

EmergencyContact#2: Relationship:

CellPhone: WorkPhone: HomePhone:

Email:

Allergy Information

Doestheparticipanthaveallergies?YesNo

Ifyes,pleaselistallallergies/reactions(food,medicine,beestings,etc.):

Iftheparticipanthasallergies,doeshe/shehaveanauto-injectionorEpi-Pen?YesNo

Iftheparticipantdoeshaveanauto-injectionorEpi-Pen,wheredoeshe/shekeepit?

Asthma

Doestheparticipanthaveasthma,wheezing,orshortnessofbreath?YesNo

Ifyes,wheredoeshe/shekeepherinhaler?


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General Health Information

Istheparticipantcurrentlytakinganymedications?YesNo

Ifyes,pleaselisteachmedicationanddosage:

1. Hasaphysicianeverrestrictedorprohibitedtheparticipantfromparticipatinginanathleticprogram/event?

YesNo

2. Doestheparticipanthaveanyrecurrent/chronicillnesses? YesNo3. Doestheparticipanthavesicklecellanemiaorsicklecelltrait? YesNo4. Doestheparticipantwearglassesorcontacts? YesNo5. Doestheparticipanthavediabetes? YesNo6. Doestheparticipanthaveaseizuredisorder,suchasepilepsy? YesNo7. Doestheparticipantcurrentlyhaveheartdiseaseoranytypeofheart

condition?

YesNo

8. Doestheparticipanthavehighbloodpressure? YesNo9. Doestheparticipanthaveanymissingorgans(i.e.kidney)? YesNo10.Doestheparticipanthavehearingproblemsorwearhearingaids? YesNo11.Doestheparticipanthaveattentiondeficitdisorder(ADD)orattention

deficithyperactivedisorder(ADHD)?YesNo

12.Doestheparticipanthaveanylearningordevelopmentaldisabilities,whichmayaffectparticipation?

YesNo

13.Doestheparticipanthaveanychronicskinconditionsorinfections? YesNoIfyouansweredyestoanyoftheabove,pleaseexplaininthespacebelow.Pleaseincludethe

questionsnumberanddates:

Pleaselistanyotherillnesses,healthconditions,orrestrictionsthatcoulddisallowtheparticipantfromsafelyparticipatingintheprogram:


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General Health History

1. Hastheparticipanteverbeenhospitalized? YesNo2. Hastheparticipanteverhadsurgery? YesNo3. Hastheparticipanteverhadaheadinjury,beenknockedout,losttheir

memory,orhadaconcussion?YesNo

4. Hastheparticipanthadmononucleosiswithinthepast6months? YesNo5. Hastheparticipanteverhadaseizure? YesNo6. Hastheparticipanteverpassedoutorfaintedduringexercise? YesNo7. Hastheparticipanteverbeendizzyduringorafterexercise? YesNo8. Hastheparticipanteverhadchestpain/discomfortduringorafter

exercise?YesNo

9. Hastheparticipanteverbeendiagnosedwithaheartcondition?(i.e.heartmurmur,MarfansSyndrome,Rheumaticfever,highcholesterol,etc.)

YesNo

10.Hastheparticipanteverbrokenorfracturedanybones? YesNo11.Hastheparticipanteverpartiallyorcompletelydislocatedanyjoints? YesNo12.Hastheparticipanteversufferedanyheatrelatedillnesses,suchasheat

strokeorheatexhaustion?YesNo

13.Hastheparticipanteverhadbackproblems? YesNo14.Hastheparticipanteverbeentreatedformental/emotionalhealth

concerns?YesNo

15.Hastheparticipanthadasignificantlifeeventthatcontinuestoaffecttheirlife?(abuse,deathofalovedone,familychangesetc.)

YesNo

Ifyouansweredyestoanyoftheabove,pleaseexplaininthespacebelow.Pleaseincludethe

questionsnumberanddates:

Acknowledgment of Understanding

Withmysignature,Iherebyacknowledgeoragree:

ThatallinformationonthisParticipantMedicalGeneralHistoryformistrueandaccuratetothebestofmyknowledge

ToprovidetheNotahBegayIIISoccerProgram(NB3SP)withanyneworrelevantmedicalinformationthatmayaffecttheParticipantsabilitytosafelyparticipateinNB3SP.

UnderstandthattheNB3SPreservestherighttorefuseparticipationifthisParticipantMedicalGeneralHistoryformisnotcompleteoraccuratelyfilledout.

Signature

PrintedNameofParent/Guardian

Signature

SignatureofParent/Guardian: Date:

*StaffOnly*:SignatureofNB3SLReviewandApproval: Date:

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