Sprague Youth Football Registration GO OLY`s!!!

Sprague Youth Football
Registration
GO OLY’s!!!
Registration Form
Parent / Guardian 1
First Name
Last Name
Address
Address (cont.)
City
State
Zip
Home Phone
Work Phone
Mobile Phone
Text Capable Y
N
| Provider___________________
Email (required)
Parent / Guardian 2
First Name
Last Name
Page 1 of 5
Registration Form
Address
Address (cont.)
City
State
Zip
Home Phone
Work Phone
Mobile Phone
Text Capable Y
N
| Provider___________________
Email
Additional Parent / Guardians Information
Additional Parent/Guardian 1 Name
Additional Parent/Guardian 1 Phone
Additional Parent/Guardian 1 Email
Additional Parent/Guardian 2 Name
Additional Parent/Guardian 2 Phone
Page 2 of 5
Registration Form
Additional Parent/Guardian 2 Email
Player
Participant Information
First Name
Middle Name
Last Name
Address
Address (cont.)
City
State
Zip
Home Phone
Email
Gender
Birthdate mm/dd/yyyy
Page 3 of 5
Registration Form
Age As Of August 1, 2016
School
Grade
Number Of Years Played
Height
ft
in
Weight
lbs
Scholarship Program
Please help support our player fee scholarship program by making a donation below. This scholarship program
allows all children in our community to participate in our programs. If you are in need of a scholarship please contact
the registrar.
By choosing a donation amount it will be added to your registration total.
I Would Like To Make A Donation In The Amount Of:
$
Concussion Compliance
Oregon State now requires that all families read and acknowledge the Concussion Compliance Law. Please click on
the following link to read and print this information. Once read, please confirm that you have read the law as
required ENCLOSED
I Have Read The Concussion Compliance Law
|
Initials______________
Initials______________
Emergency Contact & Medical Information
Please List Someone Other Than Parent/Guardian For The Emergency Contact Information.
(If Any Fields Below Not Applicable, Enter "N/A")
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Daytime Phone
Emergency Contact Evening Phone
Insurance Provider Name
Page 4 of 5
Registration Form
Insurance Provider Group Number
Insurance Provider Policy Number
Preferred Hospital
Doctors Name
Doctors Phone
Allergies / Medical Concerns
**I hereby certify that the information given here is true and complete, and I will not hold Sprague Youth
Football or its affiliates liable for any errors or omissions.
Date:____________________________
Print Name:________________________________________
Signature:_________________________________________
Official Use Only (Do Not Write In This Area)
Form Received:_____________________ (Initial)
Amount Received: $_______________________
Check Number: __________________________
Page 5 of 5
A Fact Sheet for PARENTS
WHAT IS A CONCUSSION?
April 2013
A concussion is a type of traumatic brain injury.
Concussions are caused by a bump or blow to the
head. Even a “ding,” “getting your bell rung,” or
what seems to be a mild bump or blow to the head
can be serious.
HOW CAN YOU HELP YOUR CHILD PREVENT
A CONCUSSION OR OTHER SERIOUS BRAIN
INJURY?
• Ensure that they follow their coach’s rules for
safety and the rules of the sport.
• Encourage them to practice good sportsmanship
at all times.
You can’t see a concussion. Signs and symptoms of
Make sure they wear the right protective
•
concussion can show up right after the injury or may
equipment
for their activity. Protective equipment
not appear or be noticed until days or weeks after
should fit properly and be well maintained.
the injury. If your child reports any symptoms of
Wearing a helmet is a must to reduce the risk of
•
concussion, or if you notice the symptoms yourself,
a
serious brain injury or skull fracture.
seek medical attention right away.
– However, helmets are not designed to prevent
concussions. There is no “concussion-proof”
WHAT ARE THE SIGNS AND
helmet. So, even with a helmet, it is important
SYMPTOMS OF A CONCUSSION?
for kids and teens to avoid hits to the head.
Signs Observed by Parents or Guardians
If your child has experienced a bump or blow to the
WHAT SHOULD YOU DO IF YOU THINK
head during a game or practice, look for any of the
YOUR CHILD HAS A CONCUSSION?
following signs and symptoms of a concussion:
SEEK MEDICAL ATTENTION RIGHT AWAY.
• Appears dazed or stunned
A health care professional will be able to decide
• Is confused about assignment or position
how serious the concussion is and when it is safe
• Forgets an instruction
for your child to return to regular activities,
• Is unsure of game, score, or opponent
including sports.
• Moves clumsily
KEEP YOUR CHILD OUT OF PLAY.
• Answers questions slowly
Concussions take time to heal. Don’t let your
• Loses consciousness (even briefly)
child return to play the day of the injury and
• Shows mood, behavior, or personality changes
until a health care professional says it’s OK.
Children who return to play too soon—while
Symptoms Reported by Athlete
the brain is still healing—risk a greater chance
• Headache or “pressure” in head
of having a repeat concussion. Repeat or later
• Nausea or vomiting
concussions can be very serious. They can cause
• Balance problems or dizziness
permanent brain damage, affecting your child
for a lifetime.
• Double or blurry vision
• Sensitivity to light
TELL YOUR CHILD’S COACH ABOUT ANY
• Sensitivity to noise
PREVIOUS CONCUSSION. Coaches should
• Feeling sluggish, hazy, foggy, or groggy
know if your child had a previous concussion.
• Concentration or memory problems
Your child’s coach may not know about a
concussion your child received in another sport
• Confusion
or activity unless you tell the coach.
• Just “not feeling right” or “feeling down”
It’s better to miss one game than the whole season.
For more information, visit www.cdc.gov/Concussion.
Hoja Informativa para los PADRES
¿QUÉ ES LA CONMOCIÓN CEREBRAL?
Una conmoción cerebral es una lesión en el cerebro, causada
por un golpe en la cabeza o una sacudida. Incluso una
pequeña conmoción o lo que parece ser un golpe o sacudida
leve puede ser serio.
La conmoción cerebral no puede verse. Los signos y síntomas
de una conmoción pueden aparecer inmediatamente después
de la lesión o puede que no aparezcan, o se hagan visibles
algunos días o meses después de haber sufrido la lesión. Si
su hijo tiene los signos de una conmoción cerebral o si usted
nota algún síntoma, busque atención médica de inmediato.
¿CUÁLES SON LOS SIGNOS Y SÍNTOMAS DE LA
CONMOCIÓN CEREBRAL?
Signos que notan los padres y los tutores
Si su hijo ha sufrido un golpe en la cabeza o una sacudida
durante un juego o una práctica, obsérvelo para determinar
si tiene alguno de los siguientes signos y síntomas de una
conmoción cerebral:
Abril de 2013
Versión en español aprobada por CDC Multilingual Services – Order # 4421
• Luce aturdido o fuera de control
• Se confunde con la actividad asignada
• Olvida las jugadas
• No se muestra seguro del juego, la puntuación ni de sus
adversarios
• Se mueve con torpeza
• Responde con lentitud
• Pierde el conocimiento (así sea momentáneamente)
• Muestra cambios de conducta o de personalidad
• No puede recordar lo ocurrido antes de un lanzamiento o
un caída
• No puede recordar lo ocurrido después de un lanzamiento
o un caída
¿CÓMO AYUDAR A SU HIJO A PREVENIR UNA
CONMOCIÓN CEREBRAL?
Aunque todo deporte es diferente, hay medidas que puede
tomar para protegerse.
• Haga que siga las reglas impartidas por el entrenador
y las reglas del deporte que practica.
• Invítelo a mantener el espíritu deportivo en todo momento.
• Haga que su hijo use el equipo protector adecuado según la
actividad que realiza. El equipo de protección debe ajustarse
bien, debe hacérsele el mantenimiento adecuado, y el
jugador debe usarlo correctamente y en todo momento.
¿QUÉ DEBE HACER SI CREE QUE SU HIJO HA
SUFRIDO UNA CONMOCIÓN CEREBRAL?
1. 2.
3. Síntomas que reporta el atleta
• Dolor o “presión” en la cabeza
• Náuseas o vómitos
• Problemas de equilibrio, mareo
• Visión doble o borrosa
• Sensibilidad a la luz y al ruido
• Se siente débil, confuso, aturdido o grogui
• Problemas de concentración o memoria
• Confusión
• No se “siente bien”
Es preferible perderse un juego que toda la temporada.
Para obtener más información, visite www.cdc.gov/ConcussionInYouthSports.