1/27/2019 2019_Packet_Instructions - Google Docs

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2020 Portage Pop Warner RegistrationForm Instructions

1. Please read each form carefully.

2. Participant’s Name, MUST be written EXACTLY as shown on BIRTH CERTIFICATE.

** DO NOT use nicknames**

3. 4. All forms MUST have MIDDLE NAME written out.

**Middle initials will NOT be accepted**

5. If you prefer to handwrite, please use BLACK or BLUE ink only, and print legibly.

6. ANY Forms with scratch/cross-outs or white-out will not be accepted.

7. Only Parents and Legal Guardians may register players.

8. Players MUST be present during registration.

9. Medical physical must be completed on or after 1/1/2020.

Nurse will be on site at registration to complete physical for $25 fee.

Questions & Inquiries:

Email: portagepopwarner@gmail.com

Website: www.portagepopwarner.com

1/27/2019 2019_Packet_Instructions - Google Docs

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2020 Registration Checklist

Participant’s Full Name:

Items Due At Registration

PPW Registration Form; Complete all except red sections

2020 Pop Warner Player Contract Read,and both, sign.

2020 POP WARNER PHYSICAL FORM; completed on or after 1/1/2020

**Players WILL NOT be allowed on the field if physical form has not been completed and cleared**

2020 PPW Rules & Policies; Read, initial and sign.

**PLAYOFF TEAMS **

ORIGINAL Birth Certificate must be provided at time of registration.

* Copy will be made by PPW and returned after paper certification complete

* Original will be required a 2nd time before playoffs to regional certification

Registration Fees

*Low Income assistance plan is available, please inquire if interested*

Copy of 2019-2020 School Report Card

*must have ALL (4) FOUR quarters w/no markings or highlights

***NO REFUND WILL BE ISSUED AFTER REGISTRATION**

THIS PAGE IS LEFT BLANK INTENTIONALLY

ortage Pop Warner

1. Registering for: * FOOTBALL 

CHEER 

DANCE 

 

 2. Participants Name: *

Address: * _____________________________

_____________________________

_________________________

8.Phone Number: *

3. DOB (1/1/2020): *

PPW ADMIN USE ONLY

Complete PPW Officials: 4. Age on July 31, 2020:* Jersey

1st Choice #________ 2nd Choice #________ 3rd Choice #________

5. Sibling(s) Name & Age: Raffle Ticket #’ s _____________

CHEER & DANCE DIRECTOR: _________

BUSINESS MANAGER: _________ 6. Parent/Guardian Name:* □ RC □ BC □ PC □ PHY

____________________________________ PAYMENT:REGISTRATION _______________ Other: ______________

$25 - PHYSICAL x ________ NURSE: ______________

Total: ONLINE CASH CREDIT CHECK#

Pop Warner Little Scholars, Inc. 2020 PARTICIPANT CONTRACT AND PARENTAL CONSENT FORM

Special Note: This form must be dated after January 1, 2020 and is APPLICABLE ONLY FOR THE 2020 SEASON.

This form must be submitted to your LOCAL organization prior to the athlete participating in Pop Warner. No other forms are acceptable. Every Pop Warner Association must have a fully completed and signed original of this form prior to allowing the athlete to participate.

Legal Name of Participant (must match birth certificate):

Last _________________________________ First _________________ Middle ___________________ Also known as __________

Address ________________________________________________________________________

City ___________________________________ State_____ Zip _______________________

Phone No: _______________________________ Birth date ____________________________ Gender: ___Male ___Female

Sport: _____Football _____Cheer _____Dance Mother’s Month and Day of Birth ________________________

School: _______________________________________________Grade Level: ______________

Grade Point Average: ______________________ Alternative Form Participant: ______________

(must meet Scholastic Fitness Requirement of 2.0/70% or else fill out the Scholastic Eligibility Form or Home School Eligibility Form).

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.: _________________________________

Pop Warner Official Use Only:

Registration Number: __________________________ Witnessed By: ___________________________________________

Participant Fees

Amount Paid $ __________

Type of Transaction: _____Cash _____ Check _____Credit Card ____Other (please explain)

Proof of Age verified? Yes No

Birth Certificate Other (please explain)

Division of Play (circle one): Flag / Tiny Mite / Mitey Mite / Jr. Pee Wee / Pee Wee / Jr .Varsity / Varsity / Unlimited

Weight at Time of Registration (Football Only): ___________

Proof of Scholastic Fitness verified? Yes No

1/26/2020 PWLS, INC.

2020 Parental/Guardian Permission and Waiver Participant Name: __________________________________ 1.PERMISSION TO PARTICIPATE: I, the parent/guardian of the above-named participant hereby acknowledge that my child is in good general health and I give my approval for my child to participate in any and all Pop Warner national, regional, league/conference, association and team/squad activities, including transportation to and from the activities by a licensed driver with proof of insurance. . I understand, hereby give my approval for, and assume any and all risk of my child's use of various playing surfaces and conditions, including, but not limited to, dry and wet natural and artificial grass, hard dirt, and/or mud and I hereby acknowledge and understand that said surfaces may be regular or very irregular.

2. INTENT TO INFORM: I acknowledge that I am fully aware of the potential dangers of participation in any sport and I fully understand that participation in football, cheerleading and/or dance may result in SERIOUS INJURIES, PARALYSIS, PERMANENT DISABILITY AND/OR DEATH. Furthermore, I fully acknowledge and understand that protective equipment does not prevent all participant injuries, and therefore I do hereby waive, release, absolve, indemnify, and agree to hold harmless the coaches, local, league and regional Pop Warner organization(s), Pop Warner Little Scholars, Inc., and any and all organizers, sponsors, supervisors, participants, and persons transporting the above named participant to and from activities, from any claim arising out of any injury to my/our child whether the result of negligence or for any other cause.

3.EMERGENCY MEDICAL AUTHORIZATION: I hereby grant my permission for any and all emergency medical/dental treatment and/or first aid to be administered to my child/participant, including authorizing any medical treatment facility/hospital to administer emergency treatment, for any illness/injury/accident resulting from participation in any and all Pop Warner activities.

4.EQUIPMENT RESPONSIBILITY: I agree to assume full responsibility for any and all equipment/uniforms loaned to the above named participant and I agree to promptly return, upon request, the uniform and other equipment issued to the above named participant in as good condition as when received except for normal wear and tear. If I fail to adhere to this policy, I will be responsible for the full replacement cost of such equipment.

5. INSURANCE DISCLOSURE: I am aware that my local Pop Warner organization carries group accident insurance which is considered secondary or excess for medical purposes to any and all valid insurance I possess is considered primary insurance. Furthermore, I agree to notify in writing my head coach and local Pop Warner organization of any medical claim as a result of participation in Pop Warner as soon as reasonably possible. I understand that any registration fee paid does not constitute a direct premium for insurance and that a deductible(s) may apply.

6.SCHOLASTIC VERIFICATION: I hereby stipulate that either my child is scholastically fit, or that I have completed the scholastic eligibility form or the Home School Eligibility Form and will adhere to all rules and regulations therein. Furthermore, I hereby authorize my child’s school to release school grades, report card results, and any and all other pertinent scholastic information to the local Pop Warner organization in order to comply with Pop Warner’s scholastic fitness requirements.

7.FINANCIAL RESPONSIBILITY: I hereby stipulate that I have been advised by the local Pop Warner Organization of my rights, if any, to a refund in accordance with the local organization policies, and I have also been advised of my fundraising obligations for the entire season and agree to fully comply with those obligations.

8.COMMUNICATION AND PROMOTIONAL CONSENT: As a condition to my child’s participation, I hereby consent to receive communications via email and mail from Pop Warner Little Scholars, Inc. and its partners. I understand that Pop Warner Little Scholars does not sell its contact lists and communications sent may contain program information as well as special offers and may be opted out of by following the instructions in the email or via written request to the Pop Warner National Office. Furthermore, I hereby grant to Pop Warner the absolute right and permission to make, reproduce, broadcast or otherwise use participant’s name and likeness, any photograph, films, videos, recordings, or other depictions or images in whatever form or media in connection with participation in Pop Warner throughout the universe in perpetuity and in any and all advertising and promotion materials, in any manner or media whatsoever for purposes of art, advertising, editorial, trade or promotion or any other purpose whatsoever. To the extent that any benefit accrues or may accrue to Pop Warner, I hereby and forever waive any interest in or claim to such benefits and acknowledge that Pop Warner is under no obligation to exercise any rights granted herein.

9.ADULT CODE OF CONDUCT: S1: In order to uphold the goals of Pop Warner and ensure that all participants have the benefit of a safe and fun learning environment, all parents, guardians and other adults and attendees of Pop Warner events, including but not limited to practices, competitions, and banquets, must behave accordingly in a respectful, courteous and sportsmanlike manner at all times. S2: Any adult who is using alcohol, tobacco or non-prescription drugs and/or appears intoxicated at a Pop Warner event, and/or who is flagrantly rude, attempts to intimidate, verbally abuse, heckles, taunts, ridicules, boos, throws objects and/or uses vulgarity or profane language/gestures with an official, coach, volunteer, staff member, participant or other event attendee, must receive a verbal warning and/or be asked to leave a Pop Warner event. The member organization may also provide a written warning to the individual regarding the misbehavior. The adult’s children may also be removed from the event. Any adult who commits one of the above stated offenses a second time, will be banned from any and all Pop Warner events for a period of one year from the date of the second offense, and their children may also be removed from the program(s) for that time period. S3: Any adult who physically assaults an official, coach, volunteer, staff member or participant or threatens grave bodily harm may be banned from any and all Pop Warner events for one year from the date of the offense, and their children may also be removed from any and all Pop Warner programs for that same period of time. After the ban has expired, if the individual commits another offense of the adult code of conduct, the individual will be permanently banned from any and all Pop Warner events and the individual’s children may also be permanently removed from any and all Pop Warner programs.

10. ADHERENCE TO POP WARNER RULES AND PROCEDURES: I hereby understand and acknowledge that as a parent/guardian of a Pop Warner participant it is my responsibility to comply with all rules and regulations stipulated, adopted or recognized by Pop Warner Little Scholars Inc. or any of its member organizations and understand that any non-compliance with any and all rules and regulations may be cause for discipline and/or dismissal of the participant, myself, and/or any spectators or other persons affiliated with the undersigned and the above named participant. I further understand that the participant must meet Pop Warner age and/or weight requirements on their official certification date as established by Pop Warner Little Scholars, Inc. without exception and that the decision of the Weigh Master is final. I agree to furnish an authentic certified copy of a birth certificate of the above-named participant to local Pop Warner officials and understand that valid proof of age, a current calendar year’s signed medical release, scholastic fitness form and this form must be presented by date of certification in order to participate further in Pop Warner activities. I/We hereby hold Pop Warner harmless of any financial loss as the result of any disciplinary action.

11. DISPUTE RESOLUTION POLICY SEVERABILITY: I hereby understand and acknowledge that all civil disputes between Pop Warner and any and all affiliated parties will be subject to binding arbitration in the locale of the Pop Warner Little Scholars, Inc. National Office in Langhorne, PA in accordance with Pennsylvania law under the guidelines and rules of the American Arbitration Association. I hereby agree that this binding arbitration shall be in lieu of any litigation by and between myself, Pop Warner and any and all affiliated parties. I also understand and agree that if I contest any decision or ruling of Pop Warner Little Scholars, Inc. and seek other recourse, that I will reimburse Pop Warner for all legal fees and expenses it reasonably incurs. If any portion of this form shall be deemed unenforceable, illegal, and/or invalid, the reminder shall remain in full force and effect.

RULES & REGULATIONS – In consideration of participation in Pop Warner activities and by my signature below, I hereby stipulate that I have read, fully understand and voluntarily agree to be bound by all of the above and that all information provided by me is true and accurate to the fullest extent of my knowledge.

Signature of Parent/Guardian: ________________________________________ Print Full Legal Name ___________________________________________

Signature of Participant: ___________________________________________ Print Full Legal Name ___________________________________________

Dated: ____________________________________________________________________________________________________ 1/26/2020 PWLS, INC.

Pop Warner Little Scholars, Inc.

2020 PHYSICAL FITNESS & MEDICAL HISTORY FORM

Special Note: This form must be dated after January 1, 2020 and then submitted to your LOCAL Pop Warner organization.No other forms are acceptable unless Section II is modified or substituted ONLY to comply with local and/or state laws or because of medical practitioner regulations (i.e. the medical practice insists on its own form). In either case, Section I must still be filled out entirely and attached to any modified/substituted form. Section II must be completed in its entirety ONLY by a Licensed State Examiner (medical doctor, nurse practitioner, etc.)

Section I: FOR PARENT/GUARDIAN COMPLETION ONLY

Legal Name of Participant (must match birth certificate):

Last ______________________________ First ____________________ Middle ________________

Address: ______________________________________ City:____________________________ State: ______Zip: _

Telephone No: __________________________ Date of Birth:_____________________________ Male____ Female

Name of Primary Medical Insurance Company: ______________________________ Policy Number: ____________

Membership Number: _________________Name of Primary Insured: _____________________________________

Does primary insured have Medicaid? Yes No Does primary insured have Medicare? Yes No

Sport (check one): Cheer_____ Dance_____ Tackle______ Flag_____

PARTICIPANT MEDICAL HISTORY

1. Are there any injuries requiring medical attention? Yes No2. Are there any past surgeries or scheduled surgeries? Yes No 3. Is there any history of concussions and/or head injuries? Yes No 4. Is the participant currently under the care of a medical practitioner? Yes No 5. Is the participant currently taking any medications? Yes No 6. Does the participant have any allergies (penicillin, bee stings, etc)? Yes No7. Does the participant have asthma/require the use of an inhaler? Yes No 8. Is the participant diabetic/require medication for diabetes? Yes No 9. Does the participant carry sickle cell trait/suffer from sickle cell disease? Yes No 10. Does the participant currently require medication? Yes No11. Does/has the participant have/had seizures? Yes No 12. Does the participant wear glasses or contact lenses? Yes No 13. Does the participant wear a brace or other medical support device? Yes No14. Does the participant have any other physical limitations or medical conditions? Yes No

If you answered yes to any of the above questions, please provide the question number and an explanation in the following space and/or attach to this form:

If you answered yes about concussions, provide the name of the doctor or qualified medical professional who cleared Participant for this activity: _______________________________________________________________________________

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. Furthermore, I hereby acknowledge that it is my responsibility to inform my child’s coach or organization official in writing if there is any change in the medical condition of my child. I also understand that it’s my responsibility to obtain written permission from my child’s physician on official medical stationary in order to seek permission for my child to resume participation after any and all such injury, illness or accident.

Signature of Parent or Legal Guardian: Print Name ____________________ Relationship to Participant ________ Dated

1/26/2020 PWLS, INC.

Pop Warner Little Scholars, Inc.

2020 PHYSICAL FITNESS & MEDICAL HISTORY FORM

Section II: THIS SECTION MUST BE COMPLETED ONLY BY A LICENSED MEDICAL PROFESSIONAL ON OR AFTER JANUARY 1ST of the CURRENT CALENDAR YEAR.

Name of Participant: ____________________________ (Please check the following if healthy or note otherwise):

Height Weight Eyes

Ears Mouth Nose & Throat

Respiratory Cardiovascular Neurological

Musculoskeletal Dermatological 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 Pop Warner football, cheer or dance programs. I hereby attest that this individual is physically fit and I have found no medical reason which would prevent this individual from safely participating in Pop Warner activities for the 2020 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 licensed in your state to perform physical examinations? YES NO

Today’s Date: ________________________

Please sign and fill out the following information OR place Official Medical Practice Stamp here:

Signature _____________________________________________ Printed Name ____________________

Address _________________________________________City _____________________ State_____ Zip

Phone ___________________________________ Fax: _____________________

Email/Website: Email _________________________________________ (Optional)

Section II must be completed in its entirety ONLY by a Licensed State Examiner (medical doctor, nurse practitioner, etc. – this may vary by state). NO other forms are acceptable unless Section II is modified or substituted ONLY to comply with local and/or state laws OR because of medical practitioner regulations (i.e. the medical practice insists on its own form). In either case, Section I must still be filled out entirely and attached to any modified/substituted form that MUST be signed in the current calendar year.

1/26/2020 PWLS, INC.

THIS PAGE IS LEFT BLANK INTENTIONALLY

2020 Portage Pop Warner Rules and Policies All Parents /Legal Guardians must consent to the following rules and policies and do so by initialing boxes.

REFUND POLICY : Portage Pop Warner incurs most of the expenses of a registered player long before the

season begins. Therefore, once a player has stepped on the field for practice, there will be absolutely no refund of monies.

REFUND REQUEST: All written requests for a refund must be emailed to Treasurer. Please provide a

detailed explanation. Requests can take up to six (6) weeks to process. Any refunds will be mailed to the address provided by the person(s) listed on the registration paperwork.

REGISTRATION FEE : The 2020 PPW Registration fee breakdown is located in your Registration Packet. Fees are due upon registration. The registration fee balance will be due prior to your child participating with this Pop Warner Program. Any child registering after June 9, 2020 will be required to pay the full registration amount of $500 at time of registration. If ANY participant choosing to purchase their own equipment from an outside source, registration fee will remain the same. PPW is not set up to accommodate those individuals who choose to do this.

INTENT TO INFORM : There have been many improvements made in protective equipment and teaching techniques to reduce injuries. Even so, it is important for you to know that injuries do occur and that some of these injuries can be catastrophic, such as total paralysis and even death. It is possible for this to happen to your child and it is important for you to fully understand this before allowing your child to participate

RULES AND REGULATIONS: I, as said parent/guardian understand that it is the responsibility of the parents to comply with all rules and regulations of said Association, Conference, Region, and National. Any non-compliance shall be cause for disciplinary action being taken against said candidate, parent/guardian, Team, Association and/or Region

PHOTO RELEASE: I understand that at various times during the season, photographs of players involved in the PPW program, including my child(ren) may be taken for photo galleries in print and/or season highlight videos. I agree to release photos/videos of my child(ren) for these purposes.

EQUIPMENT RESPONSIBILITY: I as parent/guardian of said candidate do hereby assume full and complete responsibility for the proper care and maintenance of all equipment, issued by the Association. I understand all equipment is to be used for Association activities only. I understand all equipment remains the property of the Association. For the safety of each player, all players must have all required equipment in order to participate in practice, pre, post and regular season games and scrimmages. Failure to do so may result in player not being allowed participate in that event. I agree to reimburse for any equipment that is lost or stolen or damaged for the value stated by the Association. Payment due when equipment was to be returned. All equipment will be returned immediately upon withdrawal from the Association. Failure to return equipment, PPW will report incident to the Conference Commissioner and a report will be filed with HLA. Failure to pay for damaged, stolen or lost equipment will be reported to the Conference Commissioner and a report will be filed with the HLA. Player and parent/ guardian will be considered in “non good standing” with PPW and the HLA and may be denied further participation in any Pop Warner Association, until the problem is resolved with PPW. It is strictly prohibited to modify any PPW equipment or personal equipment. Altering equipment in any kind of way may jeopardize your child's safety and may result in the player not being allowed to play until situation has been has been resolved. Player using any type of non approved altered/modified equipment may be asked to remove equipment and be subject to inspection by the PPW Equipment Manager or Staff Member. PPW WILL NOT be held liable for injuries sustained from any altered/modified equipment.

2020 POP WARNER ADULT CODE OF CONDUCT

We, the Portage Pop Warner Organization have implemented the following SPORT PARENT CODE OF CONDUCT for the important message it holds, about the proper role of parents in supporting their child's sports. Parents should read and understand this form PRIOR to their child(s) participating in our organization. Any parent or observer guilty of improper conduct at any game or practice will be asked to leave the field. Repeat violations may cause the guilty parties the privilege of attending all

practices and games for the remainder of the season and possible dismissal from the Program.

All members of the Portage Pop Warner Program must be aware that some behavior is unacceptable, and that there are consequences for such inappropriate actions. At the minimum, unacceptable behavior includes profanity,

obscene gestures, verbal threats and physically threatening action.

Any adult engaging in any action which reflects negatively on, or causes embarrassment to, the Pop Warner Program will be subject to disciplinary action by the association and/or conference. The Conference

Commissioner will be immediately notified of the situation and immediate action will be taken by the Association.

1. At any Pop Warner event, practice or competition, any adult who: verbally abuses; attempts to

intimidate; is flagrantly rude, or cannot control their language or action with and official, coach, or Pop Warner Volunteer, will be immediately asked to leave the Pop Warner event. His/her child(ren) may be immediately removed from the Pop Warner event.

2. Any adult that commits a second similar offense will be banned from Pop Warner events for

the remainder of the season and their child(ren) may be removed from Pop Warner for the remainder of that season.

3. Any adult who physically assaults an official, coach, or Pop Warner volunteer will be banned

from Pop Warner and their child(ren) may be removed from the Pop Warner program for one year from the date of the offense. After one year, the parent may apply for re-in statement of his or her child(ren). If the adult commits a second offense, he or she may be banned from Pop Warner and the child(ren) may be permanently removed from Pop Warner.

4. All incidents of violence, to include verbal and/or physical threats or harassment, shall be

documented and will be reported to the Conference Commissioner. Incidents will result in disciplinary action to include the Association contacting HPD is needed.

5. Portage Pop Warner Association is a drug and alcohol free environment for all programs

associated with Pop Warner. There will be a ZERO TOLERANCE for drugs and alcohol at or around any Pop Warner event. If anyone of any age commits this offense Police will immediately be called and the HLA will be notified.

Board Member(s) and/or Head Coach may approach person(s) to diffuse the situation. If safety is an issue and all

attempts have failed to halt the situation, Police may be called upon to control person(s). A follow up written warning from the Board of Directors regarding their behavior will be given to said unruly person(s). Any further

violence may result in suspension of attending practice(s), game(s) or possible dismissal from the Program.

PPW has a commitment to provide a positive environment for the youth participating in our program. It is necessary that parents, fans, etc... understand that negative and unsportsmanlike behavior impacts the positive environment. Therefore, PPW expects the parents, fans etc... to refrain from above behavior, and comply with

any and all requests made local and/or state officials while attending any event.

Legal Name: Date:

Address:

Telephone: Email:

City: State: Zip:

YES NO

Previous states resided in the past 5 years:

Date of Birth: Special Certification (i.e. CPR, Medical, etc.):

Do you have children in the program?

If yes, at what level?

Previous/current volunteer experience (e.g. baseball/softball and years):

Mailing Address (if different):

Prior/Maiden Names or Aliases:

Community affiliations (Clubs, Service Organizations, etc.):

Pop Warner Little Scholars, Inc.

2020 Official Volunteer Application (Complete BOTH Pages) Do NOT use forms from previous years.

PLEASE NOTE: A copy of a valid government-issued photo identification must be attached to this application.

Special professional training, skills, hobbies:

Date of Birth:

Have you ever been charged with or convicted of a felony? YES NO

If yes, provide your current legal status (parole, etc.)

Occupation: Have you ever been convicted of any crime involving or against a minor?

Employer: YES NO

Address: Have you ever plead guilty to,been convicted of or involved with any other type of crime?

YES NO

YES NO Have you ever been refused participation in any other youth programs?

State: YES NO

League Official:

Team Mom:

Other:

Association Name: PORTAGE POP WARNER

In which of the following would you like to participate? ("X" one or more.)

If YES to ANY of the above, explain:

Do you have a valid driver’s license?

Driver’s License#:

Special Certification (i.e. CPR, Medical, etc.):

(mm / dd / yyyy)

Social Security Number:

Assist. Coach:

Coach Trainee: Trainer:

Privacy Policy: Your privacy is important to us. PWLS does not sell or release contact information to any non-affilaited organization. However, Pop Warner and its partners may contact you with

essential program information as well as special offers and promotions. Please be advised that partners are not permitted to retain your information for non-Pop Warner use unless you specifically

grant them permission. Please contact the PWLS National Office in writing for opt out information.

Student Demo:

Head Coach: Board Member: Equipment Manager.

grant them permission. Please contact the PWLS National Office in writing for opt out information.

Name: Nature of Relationship: Phone #:

PLEASE NOTE: A copy of a valid government-issued photo identification must be attached to this application.

I hereby swear and attest that all information provided on this application is true and complete to the fullest extent of my knowledge. If I am accepted as a volunteer, Pop Warner may end the relationship immediately if I have made

any false statements or material misrepresentations, written or verbal. As a condition of volunteering, I hereby grant permission to Pop Warner to conduct a background check on me, which may include a review of database

records including but not limited to sex offender registries, child abuse and criminal history records in compliance with Pop Warner's child protection policy. I understand and agree that, if appointed, my position is conditional upon

the league receiving no inappropriate information on my background. I hereby release and agree to hold harmless from liability the local Pop Warner, Pop Warner Little Scholars, Incorporated, the officers, employees and

volunteers thereof, and/or any other person or organization that may provide such information.

I also understand that, regardless of previous appointments, Pop Warner is not obligated to appoint me to a volunteer position. I understand that, prior to the expiration of my term, I am subject to suspension by the President and

removal by the Board of Directors for any and all violations of Pop Warner policies or principles. Furthermore, I hereby attest that all contact information provided herein is up to date and I hereby grant Pop Warner Little Scholars.

Inc. and its partners permission to utilize such contact information for communications and promotions during my tenure as a volunteer.

Pop Warner Little Scholars, Inc.

Official 2020 Volunteer Application. (Page 2) Do NOT use forms from past years. (Complete BOTH Pages)

or

or

completed by:

(Choicepoint, etc.)

System(s) used for background check (minimum of one must have "X"):

Online multistate database: State/Federal Criminal History Records: FEDERAL Sex Offender Registry Other (please explain):

Background check completed by League officer:

Date Completed:

Applicant Signature Date

Applicant Name (Print or Type):

Inc. and its partners permission to utilize such contact information for communications and promotions during my tenure as a volunteer.

Binding Arbitration Policy:

If appointed, I hereby understand and agree that any and all civil disputes by and between myself, Pop Warner and any and all affiliated parties will be subject to binding arbitration in the locale of the Pop Warner

Little Scholars, Inc. National Office in Langhorne, PA in accordance with Pennsylvania law under the guidelines and rules of the American Arbitration Association. I hereby agree that this binding arbitration shall be

in lieu of any litigation by and between myself, Pop Warner and any and all affiliated parties. If any portion of this application shall be deemed unenforceable or invalid, this arbitration agreement shall still remain in

full force and effect.

NOTE: Pop Warner Little Scholars, Inc.will not discriminate against any person on the basis of race, creed, color, national origin, marital status, gender, sexual orientation or disability.

For Local Use Only. Below please print the legal name of the individual who performed the background check on the applicant and name of the local organization.Background check completed by Association officer:

(Choicepoint, etc.)

LEAGUES: You must maintain copies of background check results at the league level for the duration of the volunteer's service.

**NOTE: A State Sex Offender Registry check alone is NOT sufficient to comply with Article 21 and MUST be supplemented by one or more of the above.

Grievance Procedure

Our goal is to provide a positive experience to all members of our association. However, we

realize that from time to time an issue may arise within our organization that requires

attention. We have designed our “Grievance Policy” to provide a process in which an individual

can present an issue for review. Grievances will be based on the conduct of any members of

the Association during league related activities.

In an effort to resolve grievances in a reasonable and effective manner, we request your

cooperation in complying with the Grievance Policy. Any grievance should be presented on an

individual basis; group (pack mentality) methods will not be tolerated.

● Grievance Defined

a. Any complaint against an Association members, actions or personnel including it’s

coaches, youth participants, parents, officials, or fans and/or Board Representatives.

b. Any confrontation on the playing area, or an adjacent area, between Association

members’ personnel, coaches, youth participants, parents, officials, or fans.

The object is to resolve issues at the most immediate level.

Listed below are the steps that can be taken in the event that an issue can not be resolved and needs to be escalated.

a. The “Rules & Ethics” Committee will not hear complaints about the Constitution or Bylaws on Policies and Procedures.

b. It is the responsibility of all Association representatives to report any grievance to a “Rules & Ethics” Committee member in writing within 48 hours of occurrence. No grievance will be heard if filed outside of the time limits.

c. The “Rules & Ethics” committee will only review cases that are submitted on the official “PPW Grievance Form”.

d. The Committee may request additional information deemed necessary in rendering a decision.

e. The “Rules & Ethics” Committee will convene in person and take the matter into consideration within 72 hours of receiving the written complaint.

f. The “Rules & Ethics” Committee will hear both parties facts regarding the grievance. g. The “Rules & Ethics” Committee has the right to not accept or reject any formal written

complaint based on merit. h. “Rules & Ethics” Committee will submit their findings and recommendations to the

Board for review. i. A decision will be rendered within 7 days of the date of the written complaint. j. Board of Directors decisions are final. Complaints and decisions are then retained on file

and may be used in the disposition of other complaints or future inquiry.

Chain of Command for Grievances

Ifthereisaquestionorcomplaintagainstaplayer,aparent,amemberofthecoachingstaff,anof�icial,amemberoftheBoard,ortheBoardofDirectors,thecomplaintmustbe�iledwiththeappropriatememberintheChainofCommand.AlwaystrytoresolvetheissuewithinatonelevelbeforeproceedinguptheChainofCommand.

1stChainofCommand

Head Coach, Team Parent or Team’s Assistants Almost90%ofissuescanberesolvedbysimplytalkingtoyourcoachingstaff.

2ndChainofCommandFootball Commissioner or Cheer Director

IfyoudonotfeelyourgrievancehasbeenresolvedbytheCoachingstaff,thenyoucanapproachthePortagePopWarnerDirectorsviatheFootballCommissionerforissuesinvolvingfootballplayersorforcoachingissuesorCheerDirectorforissuesinvolvinganycheerleaders/danceparticipantsissuesorforCheercoachingissues.

Ifneitheragentisavailable(orthecomplaintisagainstthem),youmayapproachour Secretary, Safety Director or Treasurer for further information.

3rdChainofCommand

President of Portage Pop Warner and the Board of Directors -Via formal written grievance

Ifyoudonotfeelyourgrievancehasbeenresolved,bytheFootballcommissionerortheCheerDirectorthenyoucansubmitaformalcomplaintin writing tothePortagePopWarnerAssociationby�ilingaformal“GrievanceForm”.

4thChainofCommandNorthern Indiana Pop Warner Little Scholars (NIPWLS our HLA) - Via formal written grievance

FinalChainofCommandMid America Conference - Via formal written grievance

When do you contact Conference? Almost never, ThereareonlytwopeoplefromyourAssociationwhocancontactConference:theAssociationPresidentandCheerDirector.IfyouhaveanissuethatyoubelieveshouldcometotheattentionofPopWarnerConference,pleasedothisthroughoneofyourtwoConferenceRepresentatives.

IfyouhaveacomplaintagainsttheAssociation’sBoardofDirectors,then,andonlythen,mayyousubmitaformalcomplaintin writing toMAC.

AT NO TIME DO YOU EVER CALL A MID AMERICA CONFERENCE OFFICER ON THE PHONE!

When do I contact National Pop Warner?

Inaword,NEVER !NationalPopWarnerdoesn’thearcomplaintsfromanyone.

DecisionsoftheMidAmericaPopWarnerConferenceareFINAL!IfyoucontactNationalPopWarner,thecomplaintwillbereturnedtotheMidAmericaPopWarnerConference.Ifthishappens,thepersonorpersons�ilingthecomplaintwilleitherbe�inedorsuspendedfornotadheringtothechainofcommand.

Portage Pop Warner

Grievance Form

Your Name: _________________________________Phone#: ________________________________ Email: ____________________________________ Your Team Name: _________________________ Date of Incident: ____________________________ Time of Incident: __________________________ Loca�on of Incident: _________________________________________________________________

Please list a narra�ve of the events in wri�ng. List issue and any a�empts have been made to resolve it.

Signature: __________________________________________________ Date: __________________ (Person repor�ng the concern)

A�ach a second grievance form if needed. Page ____