! 2015 SUMMER SEASON REGISTRATION FORM Division: 5-6 7-8 9-10 11-12 13-15 (Please circle one) Child’s Full Name: _______________________________________________________________________________________________ Address: ________________________________________________ City_____________________ , IL Zip________________ Primary Phone #: __________________________________ Secondary Phone #: __________________________________________ Primary Email: _______________________________________ Secondary Email: _________________________________________ Birth Date: ______________________ Age As Of 06/01/2015: ___________ School Attending: ________________________________ Pictures allowed for any use such as Prime Time Athletics Website / Flyers / Facebook: YES NO (Please circle one) Father’s Name: ____________________________________ Mother’s Name: ______________________________________________ Share Same Household: YES ________ NO ________ Communication Needed For Both Parents: YES ________ NO ________ Interested in being: Head Coach / Asst. Coach (Please circle one) Coach’s Birth Date: ____________________________ Physical Disabilities? YES ______ NO _______ (If yes, please explain) ___________________________________________________ Jersey Size: Youth SM Youth MED Youth LG Adult SM Adult MED Adult LG Adult XL Adult XXL (Please circle one) Registration Fees: March 24th – March 27th = $100.00 March 28th - April 24th = $125.00 April 25th - May 21st = $145.00 LATE REGISTRATION - May 22nd - June 5th = $165.00 ANY AVAILABLE OPENINGS - After June 6th = $199.00 Payment Due At Time Of Registration: Check #______________ Cash ____________ • Payable To: Prime Time Athletics - Naperville • CC______________ Total _______________ Address: P.O. Box 24, Plainfield, IL, 60544 Coach Request ______________________________________ Friend Request _____________________________________________ NO REFUNDS will be given after last day of registration. PARENT’S CODE OF ETHICS I hereby pledge to provide positive support, care and encouragement for my child participating in sports by following this Parent’s Code of Ethics Pledge. • I will encourage good sportsmanship by demonstrating positive support for all players, coaches and officials at every game, and practice. • I will place the emotional and physical well-being of my child ahead of a personal desire to win. • I will insist that my child play in a safe and healthy environment. • I will support coaches and officials working with my child in order to encourage a positive and enjoyable experience for all. • I remember that the game is for youth and not for adults. • I will do my very best to make youth sports fun for my child. • I will ask my child to treat other players, coaches, fans and officials with respect, regardless of race, sex, creed or ability. I promise to help my child enjoy the youth sports experience by doing whatever I can, such as being a respectful fan, assisting with coaching or by being a good role model. ___________________________________________________________________ Parent / Guardian Signature ________________________________________ Date ! RELEASE OF LIABILITY FOR MINOR PARTICIPANTS READ BEFORE SIGNING IN CONSIDERATION OF _________________________________________, my child or ward, being allowed to participate in any in way in PRIME TIME ATHLETICS-related events and activities, including but not limited to flag football leagues, football camps, cheerleading and football practices (the “Events”), the undersigned acknowledges, appreciates, and agrees that: 1. The risk of injury to my child or ward from participation in the Events is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I for myself, my spouse, and my child or ward, and on behalf of our heirs, assigns, personal Representatives, executors, administrators and next of kin, KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (as defined below) or others, and assume full responsibility for my child or ward’s participation in the Events; and, 3. I willingly agree to comply with the Events’ stated and customary terms and conditions for participation. If I have any unusual or significant concern regarding my child or ward’s readiness for participation or regarding the Events themselves, I will remove my child or ward from participation in the Events and bring such concern to the attention of the nearest Prime Time Athletics official immediately; and, 4. I for myself, my spouse, my child or ward, and on behalf of my/our heirs, assigns, personal Representatives, executors, administrators and next of kin, HEREBY RELEASE AND HOLD HARMLESS Prime Time Athletics Franchise Systems, LLC, and all of its franchisees and affiliates, including but not limited to the franchise operating in my local area, in addition to all of the aforementioned entities’ owners, directors, officers, officials, agents, employees, assigns and volunteers, as well as other participants in the Events, sponsoring agencies, sponsors, advertisers, and lessors of premises used to conduct the Events (collectively, “Releasees”), WITH RESPECT TO ANY AND ALL PHYSICAL OR EMOTIONAL INJURY, DISABILITY, DEATH, or loss or damage to person or property directly or indirectly arising from or related to my child or ward’s involvement or participation in the Events, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. However, this agreement does not apply to acts of gross negligence, willful or wanton conduct, or intentional conduct by the Releasees; and 5. I for myself, my spouse, my child or ward, and on behalf of my/our heirs, assigns, personal Representatives, executors, administrators and next of kin, HEREBY AGREE NOT TO SUE, MAKE OR FILE ANY LAWSUITS, CLAIMS, PROCEEDINGS OR ANY OTHER ACTIONS OF ANY KIND WHATSOEVER against any of the Releasees for bodily injury, property damage, disability or death sustained during my child or ward’s participation in the Events to the fullest extent permitted under the law, including allegations or claims of negligence on the part of any of the Releasees; however, this agreement does not apply to acts of gross negligence, willful or wanton conduct, or intentional conduct by the Releasees. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Signature_____________________________________________________ Date_____________________________
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