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Student Athlete Information

Your Name (Last, First, MI)
Team
RKMMPWBNJRSR
Birthdate
League Age (as of 8/1/19)
Weight
Street Address
City
State
Zipcode
Cell Phone Number
Home Phone Number
Email Address
Social Networking Address

Legal Guardian Information

Your Name (Last, First, MI)
Volunteer Activity
Concession DutyTrash
Street Address
City
State
Zipcode
Cell Phone Number
Home Phone Number
Email Address
Social Networking Address

Secondary Legal Guardian Information

Your Name (Last, First, MI)
[guardian-two-name]
Volunteer Activity
Concession DutyTrash
Street Address
City
State
Zipcode
Cell Phone Number
Home Phone Number
Email Address
Social Networking Address

MEDICAL RELEASE

MY CHILD HAS ACCIDENTAL/HOSPITALIZATION INSURANCE: YesNo

Insurance Company
Policy #
Group #
Doctor's Name
Doctor Phone
Hospital Preference

Allergies (please List):


Injuries/Illnesses in the past 12 months that required hospitalization (please list)


Does your child have Asthma/Use an Inhaler?
YesNo


Does your child take daily medication or have a chronic illness? YesNo

If so please list:


Does your child have any physical limitations that we should be aware of? YesNo

If so please describe:


THIS FORM WILL BE RELEASED TO THE HEAD COACH/TEAM MOM OF YOUR CHILD’S TEAM ONLY.

I GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN ALL MPALYFCA ACTIVITIES.

Guardian Signature:
Use your finger/stylus (mobile) or mouse (desktop) to sign below.

Date

Required League Service
Game Day ConcessionsField Set UpTeam MomPractice Field ConsessionsField Clean UpCoach


PHOTO/VIDEO RELEASE

I hereby give permission for images of my child, captured during Melbourne Police Athletic League Youth Football and Cheerleading League activities through video, photo and digital camera, to be used for purposes of media including but not limited to local newspapers and the MPALYFCA website.


Signature:

Use your finger/stylus (mobile) or mouse (desktop) to sign below.

Date


Parent or Legal Guardian

Any attempt by anyone to circumvent the spirit of the rule and bylaws of the Melbourne Police Athletic League Youth Football and Cheerleading Association (MPALYFCA) and/or the Brevard county Youth Football and Cheerleading Association (BCYFCA) shall be considered a violation and will be handled in accordance with the bylaws, and /or the BCYFCA bylaws Article XVII.


PARENT/PLAYER AGREEMENT

(PLEASE INITIAL EACH ITEM TO SHOW ACCEPTANCE)

CONDUCT: I understand that a code of conduct for all participants and parents / guardians /friends will be strictly adhered to. Participants are expected to conduct themselves in a respectful manner at all times. Any participant displaying bad sportsmanship, using foul language or being disrespectful to coaches, teammates or opposing teams will be suspended or removed from the team. The use of alcohol and tobacco products will not be tolerated by parents/guardians/friends of participants Parents/guardians/friends of participants are asked not to converse with coaches, officials or participants during practices and games, and are strictly prohibited from the playing field during practices and games unless requested by a coach or official. Parents further agree that use of team email addresses for any purpose other than obtaining necessary information is strictly prohibited.
INJURY: The parent/guardian of the above participant does hereby grant approval for participation and understands all the risks and hazards associated with this activity. I hereby absolve, indemnify and hold harmless the Melbourne Police Athletic League Youth Football and Cheerleading Association (MPALYFCA), its’ organizers, sponsors and volunteer staff for any injury that may occur to my child. The MPALYFCA issues equipment that meets or exceeds county safety regulations, however, it is up to the parent/guardian/participant to exchange any ill-fitting or damaged equipment to MPALYFCA immediately to insure the safety of the participant at all times.
TRANSPORTATION: Practices will be held at Carver Park. Games will rotate throughout Brevard and Indian River counties. I understand that transportation to and from this activity is my responsibility.
ATTENDANCE: I understand that participation in this activity takes a great deal of time and dedication from both the parent/guardian and the participant. Practices begin in July, and average 4 nights per week. The regular season begins in early August, and runs into early November. All games are on Saturday. Practice and game attendance are mandatory. See head coach for attendance policy.

EQUIPMENT: I assume all responsibility for MPALYFCA issued equipment for the purpose of all activities sponsored by the Association. Custom altering of any league equipment is strictly prohibited. I accept all responsibility for the return of all league-owned equipment at the end of the season or upon request; failure to do so will result in an invoice in the amount of $300 for football, and $200 for cheerleading.
REFUNDS: I understand and accept that registration refunds will be issued as follows: 100% refund up to July 1st . AFTER JULY 1 st. There is a no refund policy. Refund requests will be discussed by the Board of Directors on a case by case basis where extenuating circumstances exist. All refund requests, must be submitted in writing to a board member. I also understand and accept that there will be a $35 fee for any bounced/returned checks.
PLAYING TIME: I understand and accept that if my child attends all required practices, he/she will play a mandatory 4-play minimum per football game. Should you have questions regarding playing time or positions for your child, please discuss this with the Head Coach in a respectful and mature manner, outside the presence of any children. Questions, problems, and/or concerns regarding coaches should be directed to the MPALYFCA Director (Jason Robbins).
VOLUNTEER TIME: I understand and agree that it is mandatory that I volunteer a minimum 10 hours per participating child during the season. I also understand that my child will be required to participate in fundraising for MPALYFCA. Team parents will keep track of all volunteer hours.

I UNDERSTAND AND AGREE TO THE MPLAYFCA RULES AND POLICIES STATED IN THIS REGISTRATION APPLICATION. FAILURE TO UPHOLD AND ABIDE BY THE ABOVE STATEMENT COULD RESULT IN THE ABOVE PARENTS AND OR CHILD BEING SUSPENDED FROM LEAGUE ACTIVITIES.


Parent/Guardian Signature

Use your finger/stylus (mobile) or mouse (desktop) to sign below.

Date