North Jersey

Crushers
646-479-9587
Stansigma@aol.com

Registration Check Off List

Name_____________________________________________
Date____________________________

Application

Waiver

Code of Conduct

Contact Form

Web & Social Media Release

Medical Form (Physical)

Birth Certificate (Copy)

Report Card

Scholastic Form

North Jersey
Crushers
646-479-9587
Stansigma@aol.com
2015 Participant Contract & Parental Consent Form
Legal Name of Participant (Must match Birth Certificate):
Last_________________________ First_____________________________ Middle______________________
Address_____________________________________________________________________________________
City___________________________________ State_________________________ Zip___________________
Phone No.______________________ Birth Date____________________ Gender ___Male ___Female
School______________________________________ Grade Level________________________________
Grade Point Average_______________
Mailing Address (If different from above)_____________________________________________________
Name of Parent/Guardian_________________________ Relationship to Athlete___________________
Address (If different from above)_____________________________________________________________
City__________________________________ State__________________________ Zip___________________
Telephone No:_______________________________ Email Address:________________________________
Emergency Contact Information (if the parent/guardian can not be reached)
Name____________________________________ Relationship to Athlete____________________________
Home Telephone No.______________________ Cell or Work No.__________________________________

North Jersey Crushers Official Use Only:

Participant Fees:
Amount Paid $_______________
Types of Transaction: _______Cash Other___________________________
Proof of Age Verified

Yes

No

Birth Certificate _____________________________________________________________________

Division of Play 12 and under
Physical Verified

Yes

14 and under

Date__________________________________________________

2015 Waiver and Release of Liability (PLEASE READ BEFORE SIGNING)

Participants Name:________________________________________________________
In consideration of being allowed to participate in any way in North Jersey Crushers athletic sports program, related events and activities, the undersigned acknowledges, and appreciates, and agree that:
The risk of injury to my child from the activities involved in these programs is significant, including the
potential for permanent disability and death, while particular rules, equipment, and personal discipline
may reduce this risk, the risk of serious injury does exist; and,
A. FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both
known and unknown, EVEN IF ARISING FROM NEGLIGENCE OF THE PARTICIPANTS, spectators or,
administrators, others, and assume full responsibility for my childs participation; and
B. I willingly agree to comply with the programs stated and customary terms and conditions for participation. If I observe any unusual significant concern in my childs readiness for participation and/or in
the program itself, I will remove my child from the participation and bring such attention of the nearest
official immediately; and
C. I, myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and
next of kin, HEREBY INDEMNIFY, RELEASE AND HOLD HARMLESS, the North Jersey Crushers its
directors, officers, officials, agents, employees, volunteers, other participants, sponsoring agencies,
sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event,
WITH RESPECT TO ANY AND ALL LIABILITIES INCIDENTS, INJURY, DISABILITY, DEATH or loss or
damage to person or property incident to my or my childs involvement or participation in this program, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the
fullest extent permitted by law.

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
FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Parent/Guardian Signature______________________________________________________________
Print_____________________________________________________________________________________
Date___________________________________
Emergency Phone Number____________________________________________
UNDERSTANDING OF RISK
I understand the seriousness of the risks involved in participation in this program, my personal responsibilities for adhering to rules and regulations, and accept them as a participant.
Participant Signature_____________________________________________________________________
Printed Name of Participant_______________________________________________________________
Date Signed______________________________________________________________________________

North Jersey
Crushers
646-479-9587
Stansigma@aol.com
Sports Physical Form
Participants Name_________________________________ Date of Birth_______________________________
Parents/Guardian____________________________________ Contact Number_________________________
Street Address__________________________________________________________________________________
City_______________________ State________ Zip Code_________________
Emergency Contact_____________________________ Emergency Contact #___________________________
Please indicate MEDICAL ALERTS such as allergic reactions, contact lenses, etc:
_________________________________________________________________________________________________
Medical History:
Athlete and parents: This health record is a critical element in the determination of an athletes risk of injury in sports. Please take the time to read and answer all questions before seeing a physician for the athletes physical examination.
1.

Has anyone in the athletes family (grandparents, mother, father, brother, sister , aunt, uncle)

YES

NO

Dont Know

died suddenly before age 50?

2.

Has the athlete ever stopped exercising because of dizziness or passed out during exercise?

YES

NO Dont Know

3.

Does the athlete have asthma (wheezing), hay fever, or coughing spells after exercising?

YES

NO Dont Know

4.

Has the athlete ever had a broken bone, had to wear a cast, or had an injury to any joint?

YES

NO Dont Know

5.

Does the athlete have a history of concussion (getting knocked out)?

YES

NO Dont Know

6.

Has the athlete ever suffered a heat-related illness (heat stroke)?

YES

NO Dont Know

7.

Does the athlete have a chronic illness or see a doctor regularly for any particular problem?

YES

NO Dont Know

8.

Does the athlete take any medication (s)?

YES

NO Dont Know

9.

Is the athlete allergic to any medications or bee stings?

YES

NO Dont Know

YES

NO Dont Know

11. Has the athlete had surgery or been hospitalized in the past year?

YES

NO Dont Know

12. Has the athlete missed more than 5 consecutive days of participation in usual activities

YES

NO Dont Know

YES

NO

10. Has the athlete had an injury in the last year that caused the athlete to miss 3 or more
consecutive days of practice or competition?

because of illness, or has the athlete had a medical illness diagnosed that has not been
resolved in the past year?
13. Are you, the athlete, worried about any problem or condition at this time?

Dont Know

Please give details_on any YES answer from the above health history
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
I hereby certify that this information is accurate to the best of my knowledge. I understand that this medical authorization may be
voided in the event of injury, illness or accident and my child may not be cleared for participation at such time.
Signature or Parent_________________________________________________ Print Name__________________________________________________
Relationship to Participant_________________________________________ Date_________________________________________________________

North Jersey
Crushers
646-479-9587
Stansigma@aol.com
2015 Physical Fitness Form
THIS SECTION MUST BE COMPLETED ONLY BY A LICENSED MEDICAL PROFESSIONAL.

Name of Participant__________________________________________________________________________
Height__________________________

Cardiovascular__________________________

Ears____________________________

Dermatological__________________________

Respiratory_____________________

Eyes____________________________________

Muskoskeletal__________________

Nose & Throat___________________________

Weight__________________________

Neurological_____________________________

Mouth___________________________

Blood Pressure__________________________

I hereby certify that I am a licensed state examiner and have examined the above named
individual and understand that he/she will be involved in participating in North Jersey
Crushers football program. I hereby swear and attest that this individual is physically fit
and I have found no medical reason which would prevent this individual from safely participating in North Jersey Crushers activities for the 2015 season. I am therefore clearing
this individual for athletic participation without limitation.
Please indicate medical profession (M.D., D.O., R.N., etc._________________________
Are you a licensed in your state to perform physical examination? YES

NO

Dated_________________________________
Please sign and fill out the following information and place Official Medical Practice
Stamp:
Doctors Name________________________________
Address______________________________________
City__________________________________________
State_________________________________________
Zip Code_____________________________________
Phone (_______) ____________-________________

STAMP HERE

North Jersey
Crushers
646-479-9587
Stansigma@aol.com

Contact Information Request

Players Name_________________________________
Address_______________________________________
Phone ________________________________________
Would you like to receive text messages:

Yes

No

#__________________________

Email Address_________________________________
We will be communicating via email and text
message. Please provide an email address and a
working number that can receive text messages
so that we can keep you updated with very important North Jersey Crushers information
throughout the season.
Thank you
North Jersey Crushers Staff

North Jersey
Crushers
646-479-9587
Stansigma@aol.com

Web & Social Media Release Form

_____________________________ has my permission to
have his name and photograph posted on the North
Jersey Crushers electronic media, including but not
limited to Web Pages, and social media such as Twitter,
YouTube, Facebook and/or Instagram pages for the 2015
North Jersey Crushers Season.
____________________________
Parent/Guardian Signature

___________________________
Players Signature

North Jersey
Crushers
646-479-9587
Stansigma@aol.com

Code of Conduct
1.

You are old enough to know the difference between right and wrong. Do what is RIGHT!

2.

Be where you are supposed to be, when you are supposed to be there and doing what you are supposed to
be doing.

3.

Football is a very physical sport. There are right ways, wrong ways and DANGEROUS ways of doing
things. Listen to the coaches when they are giving instructions so that you will not only learn the RIGHT
way to do things but, more importantly, the SAFE way.

4.

No horseplay before or after practices! You may pass, take a lap or just talk. We do not want to see tackling, hitting, chasing, etc. There will be plenty of time for all of that under the correct conditions during
practice.

5.

If something does not belong to you, leave it alone unless you have permission from the owner. Stealing
of personal property WILL result in dismissal from the team.

6.

Profanity will not be tolerated.

7.

Please be advised that there are females associated with this organization, and we are to treat them with
the same dignity and respect as we would expect.

8.

Poor sportsmanship will not be tolerated.

9.

Give us your best effort on the practice field, the playing field and in THE CLASSROOM.

10.

When coaches hand out papers or give special instructions, make sure your parents are given the information.

11.

Discipline for violations of these rules (with the exception of RULE 5) will be at the
discretion of the Head Coach.

Any situation that requires disciplinary action will be written, signed by the offender and placed in a binder to be kept
for future

I have read and agree to abide by the rules as outlined in the Players Code of Conduct in the North Jersey Crushers Organization.
Parent Signature: __________________________________________ Date:_______________
I have read and do understand, to the best of my ability, the football rules. I have discussed
these responsibilities with my parents/guardians and agree to follow the rules and policies.
Participant Signature: _______________________________________ Date:_______________