Play Now! Mail In Registration

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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 ____________
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Payable To: Prime Time Athletics - Naperville
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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
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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_____________________________