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OGDEN CITY RECREATION 2016 SPRING FLAG FOOTBALL TEAM FEE $425.00 Games will be played on Saturdays Return registration form and check (payable to OCR) to Ogden City Recreation, 1875 Monroe Blvd, Ogden UT 84401 Team Name: League: Manager/Coach: Address: City Previous Team Name: Division: Manager/Coach Contact Information Cell Phone: Carrier: Accept Text Msg? Yes No AT&T, Verizon, etc. Circle one. Day Phone: Evening Phone: E-Mail Address: Alternate Contact: Cell Phone: A Concussion/Head Injury Policy must be provided to all persons participating in this program/league and signed by participant to confirm understanding of the policy. HOLD HARMLESS / MEDICAL INSURANCE / INFORMED CONSENT AGREEMENT I, the undersigned * (on the back of this roster), in consideration of the permission granted to me by the City of Ogden and Ogden City Recreation to participate in this recreation program, do hereby release, forever discharge and agree to Hold Harmless Ogden City, Ogden City Recreation, their successors and assigns, for all claims, damages, demands, actions and causes of the action at law or in equity, arising by reason or in manner growing out of participation in Ogden City Recreation Programs. I recognize that recreation and sport activities may involve a degree of physical and/or emotional stress and may cause physical and/or emotional injuries. To the best of my knowledge, I am free from any serious health problems that would prevent me from participation in sports or recreation activities. I recognize that there are specific rules that govern play and I agree to abide by them. I acknowledge that a violation of these rules may result in my not being allowed to continue in this activity. Media Release: From time to time you may be involved in media coverage. Agreeing to media coverage does not in any way imply that you will be video taped, photographed of interviewed, it simply indicates that you give Ogden City permission to allow you to be video taped, photographed or interviewed during this recreation activity. Further, I understand that Ogden City does not provide accidental medical insurance coverage for participants while engaged in sponsored recreation activities. Securing appropriate medical insurance coverage is the responsibility of the participant, or participant’s family. For Office Use Only LEAGUE DATE RECEIPT # REGISTERED BY PAID ---PAGE BREAK--- Ogden City Recreation 2016 FLAG FOOTBALL TEAM ROSTER FORM Requested information and signature must be filled in for each player before they can participate. Team Name: League: PLAYER’S NAME ADDRESS, CITY, ZIP * SIGNATURE Acknowledgement of: Hold Harmless Agreement/Concussion-Head Injury Policy. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. ---PAGE BREAK--- OGDEN CITY RECREATION CONCUSSION AND HEAD INJURY POLICY Ogden City Recreation Division herby adopts the following policies and procedures pursuant to the Utah Protection of Athletes with head Injuries Act, UTAH CODE ANN. § 26-53-101 to -301 (2011). PURPOSE Pursuant to the passage of the Utah Protection of Athletes with Head Injuries Act, the following policy and procedures are being implemented as of December 20, 2011, by the Ogden City Recreation Division, hereby known as ‘Division’, with the intent to provide conscientious and safe athletic events. Concussions and other traumatic head injuries pose a serious risk to participants of all recreational sporting activities. POLICY It is the policy of Ogden City Recreation to inform; Division Agents, parents/legal guardians and athletes of the signs, and/or behaviors consistent with sports induced concussions/traumatic head injuries and the Divisions requirement that athletes, under the age of 18, suspected of a head injury or concussion are required to seek medical attention and procedures before return to play. GENERAL DEFINITIONS 1) “Agent” means a; coach, teacher, employee, representative or other volunteer. 2) “Athlete” or “child” means an individual participant in a recreational/sporting event or program under the age of 18. 3) “Division” means the Ogden City Recreation Division 4) “Qualified health Care Provider” means a health care provider who is licensed under Title 58 of the Utah Code and may evaluate and manage a concussion within his/her scope of practice. May include; medical doctors, doctors of osteopathy, advanced registered nurse practitioners, physician’s assistants or licensed certified athletic trainers. 5) “Sporting Event” means any of the following athletic activities that is; organized, operated, managed or sponsored by an organization: a game; (ii) a practice; (iii) a sports camp; (iv) a physical education class; a competition; or (vi) a tryout. PROCEDURE 1.0 Distribution of Policy & Collection of Consent 1.1 Before permitting an athlete to participate in a Division sporting event, the Division shall provide a written copy of this concussion and head injury policy to the athlete’s parent or legal guardian. 1.2 All Division agents shall receive a copy of and become familiar with this concussion and head injury policy. 1.3 Prior to an athlete’s participation in a Division sporting event, the athlete’s parent or legal guardian must sign and detach the form at the end of this policy or have signed the individual and or event waiver and returned it to the Division. 2.0 Suspected Concussion Procedure 2.1 If a Division agent suspects an athlete has sustained a concussion or a head injury in a sporting event, the agent or other representative must immediately remove the athlete from the sporting event. Additionally, parents should inform a Division agent if they suspect their child has sustained a concussion or head injury and ensure that the athlete is removed. The Division follows a strict policy of “When in doubt, sit them out.” 2.2 The agent who removes the athlete from the sporting event will see to it that a qualified Division agent administers any necessary first aid of which the agent is capable. If the injury is beyond any agent’s training, the agent should call 911 for assistance. 2.3 The agent who removes the athlete from the sporting event will also complete the Division accident report. The Division will retain a copy for their records and send a copy to the Ogden City Risk Management. 2.4 Upon removal the agent will also complete a Suspected Concussion Form and inform Division Administrative Staff. Division Administrative Staff will review and follow up for reinstatement of the athlete as detailed below. 2.5 When an athlete has been removed from a sporting event for suspicion of sustaining a concussion or head injury, the athlete is prohibited from participating in another Division sporting event until the athlete; 2.5.1 is evaluated by a qualified health care provider who is trained in the evaluation and management of a concussion; AND 2.5.2 provides the Division with a written statement from the qualified health care provider. 2.6 The written statement from the qualified health care provider shall state that: 2.6.1 the provider has, within three years before the day on which the written statement is made, successfully completed a continuing education course in the evaluation and management of a concussion; AND 2.6.2 the athlete is cleared to resume participation in Division sporting events. CONCUSSION INFORMATION 3.0 What is a concussion? 3.1 A concussion is a brain injury that: 3.1.1 Is caused by a bump or blow to the head; 3.1.2 Can change the way a person’s brain normally works; 3.1.3 Can occur during practices or games in any sport 3.1.4 Can happen even if a person has not been knocked out; 3.1.5 Can be serious, even if the victim has not been hit very hard 4.0 4.1 of a concussion may include the following: 4.1.1 Headache or “pressure” in the head 4.1.2 Nausea or vomiting 4.1.3 Balance problems or dizziness 4.1.4 Double or blurry vision 4.1.5 Bothered by light 4.1.6 Bothered by noise 4.1.7 Feeling sluggish, hazy, foggy or groggy 4.1.8 Difficulty paying attention ---PAGE BREAK--- 4.1.9 Memory problems 4.1.10 Transient confusion, disorientation or impaired consciousness 4.1.11 Loss of consciousness 4.2 Signs of other neurological or dysfunction include: 4.2.1 Seizures 4.2.2 Irritability 4.2.3 Lethargy 4.2.4 Fatigue 4.2.5 Does not “feel right” 5.0 Failure to Respond 5.1 What if my child/athlete continues playing with a concussion or returns too soon? 5.1.1 Concussions and head injuries pose a serious risk to participants of all recreational sporting events. They can range from mild to severe and can disrupt the way the brain normally works. All are potentially serious and may result in complications, including prolonged brain damage and death if not recognized and managed properly. 5.1.2 Continuing to play with the signs and of a concussion and/or traumatic head injury leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact with devastating and even fatal consequences. Additionally, having had one concussion significantly increases a person’s risk of having another. HOLD HARMLESS AGREEMENT HOLD HARMLESS / MEDICAL INSURANCE / INFORMED CONSENT AGREEMENT I, the undersigned * (on the back of this roster), in consideration of the permission granted to me by the City of Ogden and Ogden City Recreation to participate in this recreation program, do hereby release, forever discharge and agree to Hold Harmless Ogden City, Ogden City Recreation, and its elected officials, officers, its authorized agents, employees and volunteers, for all claims, damages, demands, actions and causes of the action at law or in equity, arising by reason or in manner growing out of participation in Ogden City Recreation Programs. I recognize that recreation and sport activities may involve a degree of physical and/or emotional stress and may cause physical and/or emotional injuries. To the best of my knowledge, I am free from any serious health problems that would prevent me from participation in sports or recreation activities. I recognize that there are specific rules that govern play and I agree to abide by them. I acknowledge that a violation of these rules may result in my not being allowed to continue in this activity. Concussion & Head Injury Policy Acknowledgement: I have read the Ogden City Concussion and Head Injury Policy. I have been informed on how to recognize the signs and and agree to abide by the policy. I understand if I am suspected of having a concussion or head injury that I will be removed from the sporting event and will not be permitted to continue participating in any Ogden City sporting events until a qualified Health Care Professional has determined it to be safe. I will provide Ogden City with a written statement by a qualified Health Care Professional acknowledging I am cleared to resume participation. Within this statement the provider must acknowledge he/she has successfully completed a continuing education course in the evaluation and management of a concussion within three years prior to the date the written statement was made. Media Release: From time to time you may be involved in media coverage. Agreeing to media coverage does not in any way imply that you will be video-taped, photographed or interviewed, it simply indicates that you give Ogden City permission to allow you to be video-taped, photographed or interviewed during this recreation activity. Further, I understand that Ogden City does not provide accidental medical insurance coverage for participants while engaged in sponsored recreation activities. Securing appropriate medical insurance coverage is the responsibility of the participant, or participant’s family.