Source:

Player Name________________________________

Soccer Program

Summer 2013 Sports and Wellness Camp Registration Packet

Thank You for Registering!

Included in this packet are the following forms:

Signatures are required on the following pages:

Page 6
January 2013

Page 9

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Soccer Program Registration Form

(Single Child)

Player 1 Information
First Name: Street Address: City: Home Phone: Tribe: Age: State: Cell Phone: School: Male Female Date of Birth: / / Last Name: Mailing Address: Zip:

T Shirt Size: Youth: S M L XL Adult: S M L XL XXL

Parent/Guardian Information
First Name: Street Address: City: Home Phone: Email Address: Emergency Contact: Phone #: State: Cell Phone: Zip: Last Name:

Participant Agreement
Please review the next 3 pages and sign at the bottom of page 6 for the NB3F Soccer Program Participant Agreement -Definition of Terms: NB3 is a collective term to refer to the Notah Begay III Foundation and its affiliated organizations,

including the San Felipe Soccer Club, Notah Begay III Soccer League, US Soccer Foundation, and all other San Felipe Soccer Club, Notah Begay III Foundation, US Soccer Foundation, and Notah Begay III Soccer League associated officers, coaches, employees, volunteers, agencies, or any other associated agent.

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Participant(s) is defined as those listed on page 1 under Participant 1 Information

Notah Begay III Foundation Soccer Program Participant Agreement Assumption of Risk, Waiver of Liability, and Indemnification Agreement About Soccer and NB3 Soccer is the worlds most popular sport, played by many players of all ages and levels. NB3 wishes to promulgate this spirit of soccer in the safest manner possible. As such, NB3 would like to ensure all participants and participant family members are aware of the risks inherent to soccer. NB3 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 and possibility of injury. We do not mean to frighten or discourage our participants, but simply increase their awareness 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 give the 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, muscle, and tendon tears are a possibility. On some occasions, more serious injuries such as concussions, broken bones, and 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 the year, making heat stroke, heat exhaustion, and sunburns an associated risk. Accordingly, it is the duty of the participant 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 NB3 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 NB3 is entirely voluntary and that I understand all inherent risks. Waiver of Liability In accordance with permission to participate in NB3 and at any other NB3 affiliated event, I, on behalf of the participant(s), my spouse, my heirs, personal representatives, or assigns do hereby release, waive, and discharge NB3, San Felipe Soccer Club, and the Notah Begay III Foundation (including its officers, coaches, employees, volunteers, 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 NB3. This agreement applies to 1) minor, major, or catastrophic injury (including death) from incidents or illnesses that may arise during a NB3 associated event or on NB3 associated premises. These premises include but are not limited to NB3 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 Clauses Indemnification I agree to hold harmless, defend, and indemnify NB3. (More precisely, defend and pay any judgment and costs, including investigation costs and attorneys fees) from any and all claims of mine, my child, my spouse, my family members, or my heirs arising from injury or loss due to participation in NB3 (including those that arise from the risks inherent to playing soccer and the ordinary negligence of NB3). Cont.
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Relevant Binding Clauses (Cont.) Covenant Not to Sue I covenant not to sue NB3 for any present or future claim arising directly or indirectly from my childs participation in NB3. This includes claims resulting from inherent risks of playing soccer and the ordinary negligence of NB3. Arbitration I agree to engage in good faith efforts to mediate any dispute that might arise between NB3 and me. 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 American Arbitration Association then in effect. I further recognize that the issue must be submitted to binding arbitration in the State of New Mexico. Venue and Jurisdiction Accordingly, I agree that if, in spite of this contract, action is brought against NB3 regarding 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, and Indemnification 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 NB3 and me and cannot be modified or changed in any way by representations or statements by any agent or employee of NB3. This agreement may only be amended by a written document duly executed by all parties. Acknowledgements, Assertions, and Agreements: 1. Health StatusI accept and assume full responsibility for consulting with a doctor about NB3 programs and events and hereby 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 and comfortably engaging in NB3 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 NB3 programs, events, or activities Possesses sufficient physical fitness and skill to enable safe participation in playing soccer

2. Emergency Care- I authorize or agree:

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NB3 to administer emergency first aid, CPR, and use of an AED when deemed necessary by NB3 or its affiliated officers NB3 to secure emergency medical care or transportation (i.e. EMS) for the participant(s) when deemed necessary by NB3 or its affiliated officers. NB3 to share my childs medical history with emergency medical personnel when deemed necessary by NB3 or its officers. To assume all costs of emergency medical care and transportation, including costs to my insurance co. 5

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 NB3 guidelines, rules and procedures of safety and general deportment while on NB3 and San Felipe Pueblo premises, whether or not the participant is engaged in training events or activities at the time. Immediately inform NB3 of any misconduct or dangerous situation during any NB3 related program or event Wear required and appropriate equipment at all times while playing

4. Further Agreements related to safety- I agree: That NB3 will conduct activities in good faith and reserves the right to terminate the participant(s)s participation if the participant(s) is incapable of safely meeting the rigors of the activity That NB3 reserves the right to terminate the participant(s)s participation if he/she disallows other participants from safely or enjoyably participating.

5. Data Collection I grant NB3 permission to collect basic health data, including height, weight, BMI and soccer performance statistics 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 the Participant(s) health measurements will be kept confidential and that the participant(s) will remain anonymous in any published data or program evaluation. 6. Media Release I understand that photos and/or video may be taken of the participant(s) for NB3 promotional purposes. NB3 has permission to take and use photos/video of the participant(s) for NB3 promotional purposes Acknowledgement 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 NB3 for injuries or death resulting from the inherent risks of playing soccer or the ordinary negligence of NB3. 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 NB3, to the greatest extent allowed by the state of New Mexico.

Signature

Printed Name of Participant:

Printed Name of Parent/Guardian:

Signature of Parent/Guardian:
January 2013

Date: 6

Signature

Soccer Program Participant General Medical History

Please Complete this Medical History form for each participant to help ensure the health and safety of every child.

Participant Information
First Name: Age: Last Name: Date of Birth: / / Gender: Male Female

Emergency Contacts Information

This is the person you would like the NB3 Soccer Program to contact in case of an emergency

Emergency Contact #1: Cell Phone: Email Address: Emergency Contact #2: Cell Phone: Email: Work Phone: Work Phone:

Relationship: Home Phone:

Relationship: Home Phone:

Allergy Information
Does the participant have allergies? Yes No If yes, please list all allergies/ reactions (food, medicine, bee stings, etc.):

If the participant has allergies, does he/she have an auto-injection or Epi-Pen? Yes No If the participant does have an auto-injection or Epi-Pen, where does he/she keep it?

Asthma
Does the participant have asthma, wheezing, or shortness of breath? Yes No If yes, where does he/she keep her inhaler?
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General Health Information

Is the participant currently taking any medications? Yes No If yes, please list each medication and dosage:

1. Has a physician ever restricted or prohibited the participant from participating in an athletic program/event? 2. Does the participant have any recurrent/ chronic illnesses? 3. Does the participant have sickle cell anemia or sickle cell trait? 4. Does the participant wear glasses or contacts? 5. Does the participant have diabetes? 6. Does the participant have a seizure disorder, such as epilepsy? 7. Does the participant currently have heart disease or any type of heart condition? 8. Does the participant have high blood pressure? 9. Does the participant have any missing organs (i.e. kidney)? 10. Does the participant have hearing problems or wear hearing aids? 11. Does the participant have attention deficit disorder (ADD) or attention deficit hyperactive disorder (ADHD)? 12. Does the participant have any learning or developmental disabilities, which may affect participation? 13. Does the participant have any chronic skin conditions or infections?

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

If you answered yes to any of the above, please explain in the space below. Please include the questions number and dates: Please list any other illnesses, health conditions, or restrictions that could disallow the participant from safely participating in the program: January 2013 8

General Health History

1. Has the participant ever been hospitalized? Yes No 2. Has the participant ever had surgery? Yes No 3. Has the participant ever had a head injury, been knocked out, lost their Yes No memory, or had a concussion? 4. Has the participant had mononucleosis within the past 6 months? Yes No 5. Has the participant ever had a seizure? Yes No 6. Has the participant ever passed out or fainted during exercise? Yes No 7. Has the participant ever been dizzy during or after exercise? Yes No 8. Has the participant ever had chest pain/discomfort during or after Yes No exercise? 9. Has the participant ever been diagnosed with a heart condition? (i.e. heart Yes No murmur, Marfans Syndrome, Rheumatic fever, high cholesterol, etc.) 10. Has the participant ever broken or fractured any bones? Yes No 11. Has the participant ever partially or completely dislocated any joints? Yes No 12. Has the participant ever suffered any heat related illnesses, such as heat Yes No stroke or heat exhaustion? 13. Has the participant ever had back problems? Yes No 14. Has the participant ever been treated for mental/ emotional health Yes No concerns? 15. Has the participant had a significant life event that continues to affect Yes No their life? (abuse, death of a loved one, family changes etc.) If you answered yes to any of the above, please explain in the space below. Please include the questions number and dates:

Acknowledgment of Understanding
With my signature, I hereby acknowledge or agree:
That all information on this Participant Medical General History form is true and accurate to the best of my knowledge To provide the Notah Begay III Soccer Program (NB3SP) with any new or relevant medical information that may affect the Participants ability to safely participate in NB3SP. Understand that the NB3SP reserves the right to refuse participation if this Participant Medical General History form is not complete or accurately filled out.

Signature

Printed Name of Parent/Guardian Date: Date:

Signature of Parent/Guardian: *Staff Only*: Signature of NB3SL Review and Approval:

January 2013

Signature