Download Sign-Up Forms - Marlington Little Dukes Football

Marlington Little Dukes
2016 NBC League Football & Cheerleading Program
THINGS YOU NEED TO KNOW!!
Dear Parents,
Following are some dates you should be aware of for upcoming Little Dukes season.
ALL forms (including physical and concussion baseline) AND payment must be in PRIOR to the first day of practice,
August 8th . Below are the important dates to keep on your calendar for the beginning of the season.
No signups after 8/12/16 unless new to district.
FOOTBALL
Football Practice Starts: Aug 8th
6:00pm-8:00pm
Mon-Thurs weeks of Aug 8th & Aug 15th
Tues-Thurs last 2 weeks of Aug
Aug 8th & 9th helmets only
Aug 10th & 11th helmet and shoulder pads
Aug 15th full contact/ all equipment
Equipment Handout
Aug 6th
10:00am-12:00pm
Marlington Youth Football Camp (K – 6)
June 20th - 23rd
10:00am-12:00pm
High School Practice Fields
$25 pre-registration/$35 at camp
After school practice:
Tues-Thurs 6:00pm - 7:30pm
Starting Oct 4th 2 day a week practice
Concussion Baseline Exam
Concorde Therapy Group
July 13th & 18th
All paperwork and payment must be
turned in PRIOR to practice
Tag Dates:
Jul 15th, 16th, 17th (Car wash on the 16th as well, need kids & parents)
Aug 12th, 13th, 14th
Aug 26th, 27th, 28th
Sept 16th, 17th
Pick up container for collection
at the middle school pavilion.
You will receive location to go to
as well.
Tag is a requirement to play/cheer or to
opt out you can pay $50. Due prior
to the first practice.
Cheer Camp: TBD
Cheer Practice Starts: Aug 8th
Tuesdays thru Thursdays
6:00-7:30pm
After school practice:
Tues & Thurs 6:00pm - 7:30pm
MLD Golf Outing
Aug 20th at Pleasant View Golf Course
Flag info to be announced once teams are set
We’re excited to have this new offering for our
program and will have the details finalized soon.
The Little Dukes Board and Trustees have been busy during the off-season electing board officers, organizing and preparing
for the upcoming season. The 2016-2017 Little Dukes Board Members are:
President, Michael Collins
Vice President, Lee Hall
Treasurer, Christy Definbaugh Cheer Advisor, Ashley Chaney
Athletic Director, Paul Boggs
Secretary, Brett Marriner
If you have any questions or would like to volunteer, please feel free to contact any board member. Mike Collins at (330)
206-3976, or Paul Boggs at (330) 206-2788, Brett Marriner at (330) 754-8729, Christy Definbaugh (330) 206-2855, Lee
Hall at (330) 206-5145, Ashley Chaney at (330) 280-4938. The Little Duke website is mldfootball.com. Volunteers
throughout the season are needed for concession stand, tag day, field set up and clean up after home games.
Marlington Little Dukes Football /Cheerleading Program
2016 Equipment Replacement Agreement
Parents, we ask that you sign for the equipment that has been or will be issued to your child for the 2016
Football/Cheerleading season. YOU and YOUR CHILD are responsible for the equipment and the uniforms from the time
they are issued. All issued equipment & uniforms need to be CLEANED and turned in on the date that will be specified
later in the season. If you or your child(ren) fail to return any issued equipment or uniform, or if the issued equipment or
uniform has been damaged beyond normal wear and tear, you will be responsible for replacing it.
We will provide ONE mouthpiece per football player. Replacement mouthpieces will cost $l.OO. If your child does not
bring a mouthpiece to practice or to a scheduled game, they will need to purchase a replacement mouthpiece, or they will not
be permitted to participate that day.
By signing the signature page, the Parent/Legal Guardian and Student-Athlete are stating that they have read and understand
their responsibilities regarding any issued equipment.
Player Replacement
Helmet
Set of Shoulder Pads
Practice Jersey
Pair of Game/ Practice Pants
Chin Strap
Girdle and Pads
Set of Thigh Pads
Set of Knee Pads
Belt
EQUIPMENT REPLACEMENT COSTS Football
Cheerleader Replacement
$130.00
Skirt
$75.00
$ 75.00
Top
$75.00
$ 20.00
$ 36.00
$ 12.00
$ 7.00
$ 5.00
$ 5.00
$ 2.00
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Marlington Little Dukes Football/Cheerleading Program
2016 Authorization and Release of Liability Agreement
As parent/guardian, I authorize the participation of my child in the NBCYFL football and cheerleading athletic program with
the Marlinton Little Dukes (MLD). I understand that this program is a nonprofit sports program for youth and that my child's
participation is voluntary. I understand that the program is organized by the NBCYFL and the MLD and every one involved
in the running of the programs are volunteers. I further understand and agree that my child 's participation in athletic and other
activities of the program necessarily involves the risk of injury and even death from various causes, including but not limited
to accidents, falls, strenuous and prolonged physical activity, dehydration, illness, collision, or dispute with other participants,
weather related injuries, playing area and equipment defects, and negligence of coaches and referees. On behalf of my child,
me, and my family, I assume these risks. In consideration of the privilege of my child's participation in the program, and on
behalf of my child and me as parent/guardian, I hereby release, discharged hold harmless and indemnify, and covenant not to
sue, the NBCYFL and MLD, and all of the volunteers, associated with the program as to any and all claims of my child, me,
and other family members for personal injuries suffered be my child , property damage, medical expenses, and economic loss
arising directly or indirectly out of my child's participation in the program, and any first aid, medical care or treatment
provided to my child in the event my child is injured or becomes ill while participating in program activities, and excepting
claims that may not be released under applicable law. This Release of Liability shall be broadly construed to include all
claims and rights that the child, that I as a parent /guardian, and that other family members may have. I am a legally
responsible parent or guardian of my child. If any provision of this Release of Liability is deemed invalid, the remaining
provisions shall remain in full force and effect. This Release of Liability shall be binding on my, my heirs, next of kin, legal
representatives, beneficiaries, and successors.
My signature on the Authorization and Release section of the signature page indicates that all information provided is true
and accurate, and that I fully agree to all statements made on the Authorization and Release of Liability.
MARLINGTON LITTLE DUKES MULTIPLE RELEASE/AGREEMENT SIGNATURE PAGE
2016 SEASON
Signatures for Player/Cheerleader Code of Conduct
I was provided a copy of the NBCYFL Player/Cheerleader Code of Conduct. I have read, understand, and agree to follow the
Code of conduct and Responsibilities outlined in the Player/Cheerleader Code of Conduct for the entire duration of the
football/cheerleading season.
Student-Athlete Name
Student-Athlete Signature
Date
I (the Parent/Legal Guardian of the above signed Student-Athlete) have also read and understand the
expectations/ responsibilities for my child outlined in the NBCYFL Player/Cheerleader Code. I hereby grant him/her
permission to participate in the NBC under the NBCYFL Player/Cheerleader Code of Conduct.
Parent/Guardian Name
Parent/Guardian Signature
Date
Signature for Parent Code of Conduct
I, (the Parent/Legal Guardian of the above signed Student/ Athlete) was provided a copy of the NBCYFL Parent Code of Conduct I
have read, understand, and agree to follow the rules and guidelines as outlined in the Parent Code of Conduct for the duration of
the football/cheerleading season. If I fail, at any point in time in the season, to abide by these rules and guidelines, I
understand that I may be subjected to disciplinary action as outlined in the NBCYFL Parent Code of Conduct.
Parent/Guardian Name
Parent/Guardian Signature
Date
Signatures for Equipment Replacement Agreement
By signing bdow, we (the Parent/Legal Guardian AND Student-Athlete) are stating that they/ we read and understand our
responsibilities program, along with the replacement cost, of any issued equipment/ uniforms as outlined in the NBC Equipment
Replacement Agreement.
Parent/Guardian Name
Parent/Guardian Signature
Date
Signature for Authorization and Release of Liability
My signature below indicates that all information provided is true and accurate, and that I fully agree to all statements made on
the Authorization and Release of Liability.
Parent/Guardian Name
Parent/Guardian Signature
Date
Student-Athlete Media Release
Check one of the following options:
I DO give permission
I DO NOT give permission
To the Marlington Little Dukes Football/Cheerleading Program to include my Student-Athlete 's picture by photograph, slide, or
voice/image via audio or recording releases to the media and/or computer web pages.
Parent/Legal Guardian Signature
Date
Please retain the Player/Cheerleader Code of Conduct, Parent/Guardian Code of Conduct and Equipment Replacement
Agreement for your own records to reference throughout the season. Please turn in the Multiple Release/Agreement Signature
Page.
Ohio High School Athletic Association
PREPARTICIPATION PHYSICAL EVALUATION 2016-2017
Page 1 of 6
HISTORY FORM – Please be advised that this paper form is no longer the OHSAA standard.
(Note: This form is to be filled out by the student and parent prior to seeing the medical examiner.)
Date of Exam _________________________________________________________________________________________________________________________________________
Name ___________________________________________________________________________________________________ Date of birth ________________________________
Sex _________ Age _________ Grade ___________ School ___________________________________________________Sport(s)
_____________________________________
Address _____________________________________________________________________________________________________________________________________________
Emergency Contact: _________________________________________________________________________________________ Relationship ___________________________________
Phone (H) __________________________ (W) _________________________ (Cell) __________________________(Email) _____________________________________________________
Medicines and Allergies: Please list the prescription and over-the-counter medicines and supplements (herbal and nutritional-including energy drinks/ protein supplements) that you are
currently taking
Do you have any allergies?
Yes
Medicines
No If yes, please identify specific allergy below.
Pollens
Food
Stinging Insects
Explain “Yes” answers below. Circle questions you don’t know the answers to.
GENERAL QUESTIONS
1. Has a doctor ever denied or restricted your participation in sports for any
reason?
2. Do you have any ongoing medical conditions? If so, please identify
below:
Asthma
Anemia
Diabetes
Infections
Other: _________________________________________________
3. Have you ever spent the night in the hospital?
4. Have you ever had surgery?
HEART HEALTH QUESTIONS ABOUT YOU
5. Have you ever passed out or nearly passed out DURING or AFTER
exercise?
6. Have you ever had discomfort, pain, tightness, or pressure in your chest
during exercise?
7. Does your heart ever race or skip beats (irregular beats) during exercise?
8. Has a doctor ever told you that you have any heart problems? If so, check
all that apply:
□ High blood pressure
□ A heart murmur
□ High cholesterol
□ A heart infection
□ Kawasaki disease
Other: __________________________
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG,
echocardiogram)
10. Do you get lightheaded or feel more short of breath than expected during
exercise?
11. Have you ever had an unexplained seizure?
12. Do you get more tired or short of breath more quickly than your friends
during exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
13. Has any family member or relative died of heart problems or had an
unexpected or unexplained sudden death before age 50 (including
drowning, unexplained car accident, or sudden infant death syndrome)?
14.
Yes
No
Yes
No
Yes
No
Yes
No
Does anyone in your family have hypertrophic cardiomyopathy, Marfan
syndrome, arryhthmogenic right ventricular cardiomyopathy, long QT
syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic
polymorphic ventricular tachycardia?
15.
Does anyone in your family have a heart problem, pacemaker, or implanted
defibrillator?
16. Has anyone in your family had unexplained fainting, unexplained seizures,
or near drowning?
BONE AND JOINT QUESTIONS
17. Have you ever had an injury to a bone, muscle, ligament, or tendon that
caused you to miss a practice or game?
18. Have you ever had any broken or fractured bones or dislocated joints?
19. Have you ever had an injury that required x-rays, MRI, CT scan, injections,
therapy, a brace, a cast, or crutches?
20. Have you ever had a stress fracture?
21. Have you ever been told that you have or have you had an x-ray for neck
instability or atlantoaxial instability? (Down syndrome or dwarfism)
BONE AND JOINT QUESTIONS - CONTINUED
22. Do you regularly use a brace, orthotics, or other assistive device?
23. Do you have a bone, muscle, or joint injury that bothers you?
24. Do any of your joints become painful, swolllen, feel warm, or look red?
25. Do you have any history of juvenile arthritis or connective tissue disease?
Yes
No
MEDICAL QUESTIONS
26. Do you cough, wheeze, or have difficulty breathing during or after exercise?
27. Have you ever used an inhaler or taken asthma medicine?
28. Is there anyone in your family who has asthma?
29. Were you born without or are you missing a kidney, an eye, a testicle (males),
your spleen, or any other organ?
30. Do you have groin pain or a painful bulge or hernia in the groin area?
31. Have you had infectious mononucleosis (mono) within the past month?
32. Do you have any rashes, pressure sores, or other skin problems?
33. Have you had a herpes (cold sores) or MRSA (staph) skin infection?
34. Have you ever had a head injury or concussion?
35. Have you ever had a hit or blow to the head that caused confusion,
prolonged headaches, or memory problems?
36. Do you have a history of seizure disorder or epilepsy?
37. Do you have headaches with exercise?
38. Have you ever had numbness, tingling, or weakness in your arms or
legs after being hit or falling?
39. Have you ever been unable to move your arms or legs after being hit or falling?
40. Have you ever become ill while exercising in the heat?
41. Do you get frequent muscle cramps when exercising?
42. Do you or someone in your family have sickle cell trait or disease?
43. Have you had any problems with your eyes or vision?
44. Have you had an eye injury?
45. Do you wear glasses or contact lenses?
46. Do you wear protective eyewear, such as goggles or a face shield?
47. Do you worry about your weight?
48. Are you trying to gain or lose weight? Has anyone recommended that you do?
49. Are you on a special diet or do you avoid certain types of foods?
50. Have you ever had an eating disorder?
51. Do you have any concerns that you would like to discuss with a doctor?
FEMALES ONLY
52. Have you ever had a menstrual period?
53. How old were you when you had your first menstrual period?
54. How many periods have you had in the last 12 months?
Yes
No
Explain "yes" answers here
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of Student________________________________________________Signature of parent/guardian____________________________________________________________Date: ________________________
The student has family insurance
Yes
No If yes, family insurance company name and policy number: _____________________________________________________________________________.
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy
of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. -Revised 1/13
Ohio High School Athletic Association
PREPARTICIPATION PHYSICAL EVALUATION
PHYSICAL EXAMINATION FORM
2016-2017
Page 3 of 6
Name ___________________________________________________________________________________________________ Date of birth ________________________________
PHYSICIAN REMINDERS
1. Consider additional questions on more sensitive issues.
 Do you feel stressed out or under a lot of pressure?
 Do you ever feel sad, hopeless, depressed or anxious?
 Do you feel safe at your home or residence?
 Have you ever tried cigarettes, chewing tobacco, snuff, or dip?
 During the past 30 days, did you use chewing tobacco, snuff, or dip?
 Do you drink alcohol or use any other drugs?
 Have you ever taken anabolic steroids or used any other performance supplement?
 Have you ever taken any supplements to help you gain or lose weight or improve your performance?
 Do you wear a seat belt, use a helmet or use condoms?
 Do you consume energy drinks?
2. Consider reviewing questions on cardiovascular symptoms (questions 5-14).
EXAMINATION
DATE OF EXAMINATION ______________________________
Height
BP
□
Weight
/
(
/
)
Pulse
Vision R 20/
MEDICAL
Male
L20/
NORMAL
□
Female
Corrected
□
Y
□
N
ABNORMAL FINDINGS
Appearance
Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,
arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
Eyes/ears/nose/throat
Pupils equal
Hearing
Lymph nodes
Heart
Murmurs (auscultation standing, supine, +/- Valsalva)
Location of the point of maximal impulse (PMI)
Pulses
Simultaneous femoral and radial pulses
Lungs
Abdomen
Genitourinary (males only)
Skin
HSV, lesions suggestive of MRSA, tinea corporis
Neurologic
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
Functional
Duck walk, single leg hop
aConsider
ECG, echocardiogram, or referral to cardiology for abnormal cardiac history or exam.
GU exam if in private setting. Having third part present is recommended.
cConsider cognitive or baseline neuropsychiatric testing if a history of significant concussion.
bConsider
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy
of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. -Revised 1/13
PREPARTICIPATION PHYSICAL EVALUATION
2016-2017
Page 4 of 6
CLEARANCE FORM
Note: Authorization forms (pages 5 and 6) must be signed by both the parent/guardian and the student.
Name ______________________________________________________________ Sex
□M □F
Age ____________________ Date of birth ________________________________
□ Cleared for all sports without restriction
□ Cleared for all sports without restriction with recommendations for further evaluation or treatment for _________________________________________________________
_________________________________________________________________________________________________________________________________________
□ Not Cleared
□ Pending further evaluation
□ For any sports
□ For certain sports _____________________________________________________________________________________________________________
Reason _____________________________________________________________________________________________________________________
Recommendations_____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
I have examined the above-named student and completed the pre-participation physical evaluation. The student does not present apparent clinical
contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to
the school at the request of the parents. In the event that the examination is conducted en masse at the school, the school administrator shall retain a copy of the
PPE. If conditions arise after the student has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential
consequences are completely explained to the athlete (and parents/guardians).
Name of physician or medical examiner (print/type) ___________________________________________________________________ Date of Exam ___________________
Address ______________________________________________________________________________________________ Phone ________________________________
Signature of physician/medical examiner ___________________________________________________________________________________, MD, DO, D.C., P.A. or A.N.P.
EMERGENCY INFORMATION
Personal Physician _______________________________________________________________________Phone _______________________________________________
In case of Emergency, contact _____________________________________________________________ Phone _______________________________________________
Allergies_____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Other Information _____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy
of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. -Revised 1/13