2015 FALL SEASON REGISTRATION FORM
SOUTH GILBERT / QUEEN CREEK LOCATION
Division: 5-6
7-8
9-10
11-12
13-15
(Please circle one)
Child’s Full Name: _______________________________________________________________________________________________
Address: ________________________________________________
City_____________________ AZ
Zip________________
Primary Phone #: __________________________________ Secondary Phone #: __________________________________________
Primary Email: _______________________________________ Secondary Email: _________________________________________
Birth Date: ______________________ Age As Of 08/01/2015: ___________ 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 28 - April 30 = $99.00 May 1 - May 31 = $119.00 June 1 - June 30 = $139.00 July 1 - Aug 15 = $159.00
Late Registration (AFTER Aug 15) - $199.00
Payment Due At Time Of Registration: Check #______________ Cash ____________
•
Payable To: Prime Time Athletics - South Gilbert / Queen Creek
•
CC______________ Total _______________
Address: 8490 S Power Rd #105-210 Gilbert, AZ 85297
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 a 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_____________________