2009 PARTICIPANT CONTRACT AND PARENTAL CONSENT FORM

Special Note: This form must be dated after January 1, 2009 and is applicable only for the 2009 season. This form must be submitted to your LOCAL Pop Warner organization prior to the athlete participating in Pop Warner. No other forms are acceptable. Every Pop Warner Association must have a fully completed and signed original of this form prior to allowing the athlete to participate.

Legal Name of Participant (must match birth certificate):

Last ___________________________________First_________________Middle____________ Also known as__________________________________________________________________ Address_______________________________________________________________________ City____________________________________State___Zipcode_________________________ Phone No:_______________________________ Birth date______________________________ Gender: ___Male ___Female Sport: ___Football ___Cheer ___Dance School:________________________________________________Grade Level:_______________ Grade Point Average:_________________ Alternative Form Participant:______________

(must meet Scholastic Fitness Requirement of 2.0/70% or else fill out the Scholastic Eligibility Form or Home School Eligibility Form). Mailing Address if different from above:

Name of Parent/Guardian________________________________________________________________ Relationship to Athlete:_________________________________________________________________ Address (if different from above)__________________________________________________________ City____________________________________State_____ Zipcode_____________________________ Telephone No:___________________________Email Address:__________________________________

Emergency Contact Information (if the parent/guardian can not be reached):

Name ___________________________________________Relationship to Athlete___________________ Home Telephone No:___________________________ Cell or work No.:___________________________

Pop Warner Official Use Only:

Registration Number: __________________________ Witnessed By:______________________________________________

Participant Fees Amount Paid $___________ Type of Transaction: ___Cash ___ Check ___Credit Card __Other (please explain)

Proof of Age verified? Yes No Birth Certificate Other (please explain)

Division of Play (circle one): Flag / Tiny Mite / Mitey Mite / Jr.Pee Wee / Pee Wee / Jr .Midget / Midget / U/L Weight at Time of Registration (Football Only):____________ Proof of Scholastic Fitness verified? Yes No

1/16/2009

2009 Parental/Guardian Permission and Waiver Participant Name: _____________________________________

1. PERMISSION TO PARTICIPATE

I, the parent/guardian of the above-named participant hereby acknowledge that my child is in good general health and I give my approval for my child to participate in any and all Pop Warner national, regional, league/conference, association and team/squad activities, including transportation to and from the activities by a licensed driver with proof of insurance.

2. INTENT TO INFORM

I acknowledge that I am fully aware of the potential dangers of participation in any sport and I fully understand that participation in football, cheerleading and/or dance may result in SERIOUS INJURIES, PARALYSIS, PERMANANET DISABILITY AND/OR DEATH. Furthermore, I fully acknowledge and understand that protective equipment does not prevent all participant injuries, and therefore I do hereby waive, release, absolve, indemnify, and agree to hold harmless the local, league and regional Pop Warner organization(s), Pop Warner Little Scholars, Inc., and any and all organizers, sponsors, supervisors, participants, and persons transporting the above named participant to and from activities, from any claim arising out of any injury to my/our child whether the result of negligence or for any other cause.

3. EMERGENCY MEDICAL AUTHORIZATION

I hereby grant my permission for any and all emergency medical/dental treatment and/or first aid to be administered to my child/participant, including authorizing any medical treatment facility/hospital to administer emergency treatment, for any illness/injury/accident resulting from participation in any and all Pop Warner activities. Initial: _________________

4. EQUIPMENT RESPONSIBILITY

I agree to assume full responsibility for any and all equipment/uniforms loaned to the above named participant and I agree to promptly return, upon request, the uniform and other equipment issued to the above named participant in as good condition as when received except for normal wear and tear. If I fail to adhere to this policy, I will be responsible for the replacement cost of such equipment. I agree to furnish an authentic certified copy of a birth certificate of the above-named participant to local Pop Warner officials.

5. INSURANCE DISCLOSURE

I am aware that my local Pop Warner organization carries group accident insurance which is considered secondary or excess for medical purposes to any and all valid insurance I possess is considered primary insurance. Furthermore, I agree to notify in writing my head coach and local Pop Warner organization of any medical claim as a result of participation in Pop Warner as soon as reasonably possible. I understand that any registration fee paid does not constitute a direct premium for insurance and that a deductible(s) may apply.

6. SCHOLASTIC VERIFICAITON

I hereby stipulate that (check one) ____ my child is scholastically fit, or ____ that I have completed the scholastic eligibility form or the Home School Eligibility Form and will adhere to all rules and regulations therein. Furthermore, I hereby authorize my child’s school to release school grades, report card results, and any and all other pertinent scholastic information to the local Pop Warner organization in order to comply with Pop Warner’s scholastic fitness requirements.

7. FINANCIAL RESPONSIBILITY

I hereby stipulate that I have been advised by the local Pop Warner Organization of my rights, if any, to a refund in accordance with the local organization policies, and I have also been advised of my fundraising obligations for the entire season and agree to fully comply with those obligations.

8. COMMUNICATION CONSENT

As a condition to my child’s participation in Pop Warner, I hereby consent to receive communications via email and mail from Pop Warner Little Scholars, Inc. and its partners. I understand that Pop Warner Little Scholars does not sell its contact lists and communications sent may contain program information as well as special offers and may be opted out of by following the instructions in the email or via written request to the Pop Warner National Office.

9. ADULT CODE OF CONDUCT:

S1: In order to uphold the goals of Pop Warner and ensure that all participants have the benefit of a safe and fun learning environment, all parents, guardians and other adults and attendees of Pop Warner events, including but not limited to practices, competitions, and banquets, must behave accordingly in a respectful, courteous and sportsmanlike manner at all times. S2: Any adult who is using alcohol, tobacco or non-prescription drugs and/or appears intoxicated at a Pop Warner event, and/or who is flagrantly rude, attempts to intimidate, verbally abuse, heckles, taunts, ridicules, boos, throws objects and/or uses vulgarity or profane language/gestures with an official, coach, volunteer, staff member, participant or other event attendee, must receive a verbal warning and/or be asked to leave a Pop Warner event. The member organization may also provide a written warning to the individual regarding the misbehavior. The adult’s children may also be removed from the event. Any adult who commits one of the above stated offenses a second time, will be banned from any and all Pop Warner events for a period of one year from the date of the second offense, and their children may also be removed from the program(s) for that time period. S3: Any adult who physically assaults an official, coach, volunteer, staff member or participant or threatens grave bodily harm may be banned from any and all Pop Warner events for one year from the date of the offense, and their children may also be removed from any and all Pop Warner programs for that same period of time. After the ban has expired, if the individual commits another offense of the adult code of conduct, the individual will be permanently banned from any and all Pop Warner events and the individual’s children may also be permanently removed from any and all Pop Warner programs.

9. I understand that my child must meet Pop Warner age and/or weight requirements on their official certification date as established by Pop Warner Little Scholars, Inc. without exception. I further understand that the decision of the Weigh Master is final. I understand that proof of age; (I agree to furnish an authentic certified copy of a birth certificate of the above-named participant to local Pop Warner officials), current year medical release, Participant Contract and Parent Consent and scholastic fitness must be presented by date of certification in order to participate further in Pop Warner activities.