Wednesday, November 24, 2010

4 PM – 5:30 PM

Boys and Girls ages 9 – 14

The Omaha Sports Complex

at 147th and Giles Rd

FREE ADVANCE REGISTRATION

 

YOUTH CLINIC FORM   1

Youth Football and Cheerleading Clinics

Wednesday, November 24, 2010

4 PM – 5:30 PM

Boys and Girls ages 9 – 14

The Omaha Sports Complex at 147th and Giles Rd

I-80 and take the Sapp Brothers Exit (HWY 50/144th).  Giles is north of the exit as you get to the bottom of a hill.

Registration Form

I am registering my child for the ___Football or ___Cheerleading Clinic; check one.

Complete one form for each youth registering.

Participant’s Name (Last Name, First Name) __________________________________________

Participant’s Date of Birth___________ Age____

For Boys - Football:  Participant’s Preferred Position (Offense -QB, Running Back, Receiver, Line

or Defense – Safety, Linebacker) ______________________________________

For Girls - Cheerleading:   Check the box that fits your skill level - ___Level 1 (little or no dance experience) 

___Level 2 (intermediate dancer)   ___Level 3 (advanced dancer)

 

Participant’s Parent or Guardian (Last Name, First Name) _____________________________

Address_______________________________________

City, State, Zip Code_______________________________ Home Phone___________ Cell Phone _________

 E-mail_________________________________

Emergency Contact Name   __________________________ Relationship   ________________

Home Phone____________________________ Cell Phone_________________________

2nd Emergency Contact Name_________________________ Relationship_____________

Home Phone____________________________ Cell Phone_________________________

Health Insurance

Company____________________ Policy Number_____________________

 Group Number_______________________ Policy Holder’s Name__________________ 

Family Doctor______________ City_______________ Phone_______________________

 Check here if you need transportation: __________ (Please arrange your own transportation if at all possible; we cannot guarantee that we can transport your child.)

 

 

YOUTH CLINIC FORM   2

 

Health History for Registered Child – Name of Child_______________________

Does your child have any pre-existing or present medical conditions?  If yes, please explain:

_______________________________________________________________________________

 _______________________________________________________________________________

_______________________________________________________________________________

Please give the name and dosage of any medication your child is currently taking and any medications he/she has taken in the last 6 months:

_______________________________________________________________________________

 _______________________________________________________________________________

_______________________________________________________________________________

Does your child have any allergies?  If yes, what are they?

_______________________________________________________________________________

 _______________________________________________________________________________

_______________________________________________________________________________

Please check any or all that apply:

Hay Fever__

Insect Bites__

Asthma__

Diabetes__

Heart Condition__

Epilepsy__

Nervous Disorders__

Physical Handicap__

Other__

If any of the above is checked, please give details of each condition and include an explanation of the treatment/s and if your child has had any allergic reaction to the treatment/s:

_______________________________________________________________________________

 _______________________________________________________________________________

_______________________________________________________________________________

Has your child had any major illness/es in the past year?  If yes, please explain:

_______________________________________________________________________________

 _______________________________________________________________________________

_______________________________________________________________________________

Date of Last tetanus shot for your child_____   Do your child wear contact lenses? _________

Does your child have activity restrictions that would prevent him/her from fully participating in this clinic?  If yes, please explain:

_______________________________________________________________________________

 _______________________________________________________________________________

_______________________________________________________________________________

 

 

YOUTH CLINIC FORM   3

UFL Championship Youth Sports Clinics

Medical and Liability Release Statement

 

I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the person/s listed as emergency contact/s for this child.  If my child/ward is injured during the activity dates shown on this form and I cannot be reached, I hereby give my permission for the coaching staff of the UFL Championship Youth Sports Clinics or the management of The Omaha Sports Complex to seek immediate medical care.   I also give the physician and/or dentist permission to begin medical treatment immediately. 

 

I understand that extreme safety precautions will be taken at all times by the UFL Championship Youth Sports Clinics and its agents during the Youth Sports Clinics.  I understand the possibility of unforeseen hazards and know that there are inherent risks involved for participants attending football camp.  I agree NOT to hold the UFL, the City of Omaha, clinic coaches and volunteers and The Omaha Sports Complex financially liable for damages or injuries incurred by the child athlete whose parent/guardian signs this form.  I agree NOT to hold The Omaha Sports Complex, their employees and volunteers liable for any damages, losses or injuries incurred by the child athlete whose parent/guardian signs this form.  I understand that I am financially responsible for my child/ward’s medical care should it be required.

 

Name of Child Registered: _________________________

 

Parent or Guardian’s Signature: ____________________________

 

 Relationship to Child: ____________________ Date: __________________