Collierville Parks, Recreation & Cultural Arts
SCHOLARSHIP REQUEST FORM
*Must be accompanied by a copy of the Free/Reduced Lunch form from school*
Sport you are registering for: ______
PARENT INFORMATION:
Parent/Guardian First Name: ______Parent/Guardian Last Name: ______
Street: ______Primary Email: ______
Additional Email: ______
City: ______State: ______ZIP: ______
Daytime Phone: ______Evening Phone: ______
PLAYER INFORMATION:
First Name of Player: ______Last Name of Player: ______
Gender: Male Female Birthdate: ______/ ______/ ______
School: ______Coach/Player Request (if permitted): ______
Do you wish to be a Head Coach: Yes No Grade (as of cutoff date): ______
Age (as of cutoff date): ______Years’ Experience: ______
HOLD HARMLESS AGREEMENT
I, the undersigned team, understand that myself and every player on the team are to act in a sportsmanlike manner at all times, and agree thatevery playershall abide by the following: use of acceptable language and social behavior, refrain from use of alcohol, tobacco, or illegal drugs,and show respect towards game officials and staff at all times. I understand that if my language, behavior or attitude with players, other spectators, or officials is negative, I will be subject to being reprimanded and/or possible suspension according to the Town of Collierville Participation Behavior Policy.
I/We do further hereby release, absolve, indemnify and hold harmless the Town of Collierville, Parks, Recreation and Cultural Arts Department, the organizers, sponsors, service provider, supervisors, all employees thereof, and/or all of the above, incidental to the conduct of activities and transportation to and from such. In case of injury, I likewise waive all claims against the organizers, sponsors, employees, or any instructors appointed by them. I/We imply that all information given on this form is true and understand that suspension from Collierville Programs and Facilities is possible if any information is false. By clicking "Continue" below, it certifies that I have read and understand the requirements for my child and myself as a parent/guardian, to participate on Town of Collierville facilities. I also understand that I can download a copy of the Parent/Participant Manual and the Parent/Participant Behavior Policy. www.collierville.com
CODE OF CONDUCT
Youth sports programs play an important role in promoting the physical, social and emotional development of children. It is therefore essential for parents and coaches to encourage youth athletes to embrace the values of good sportsmanship. Moreover, adults involved in youth sports events should be models of good sportsmanship and should lead by example by demonstrating fairness, respect, and self-control.
I therefore pledge to be responsible for my words and actions while attending, coaching, or participating in a youth sports event and shall conform my behavior to the following code of conduct:
1. I will not engage in unsportsmanlike conduct with any coach, parent, player, participant, official or any other attendee.
2. I will not encourage my child, or any other person, to engage in unsportsmanlike conduct with any coach, parent, player, participant, official or any other attendee.
3. I will not engage in any behavior which would endanger the health, safety or wellbeing of any coach, parent, player, participant, official or any other attendee.
4. I will not encourage my child, or any other person, to engage in any behavior which would endanger the health, safety or wellbeing of any coach, parent, player, participant, official or any other attendee.
5. I will not use drugs or alcohol while at a youth sports event and will not attend, coach, officiate or participate in a youth sports event while under the influence of drugs or alcohol.
6. I will not permit my child, or encourage any other person, to use drugs or alcohol at a youth sports event and will not permit my child, or encourage any other person, to attend, coach, officiate or participate in a youth sports event while under the influence of drugs or alcohol.
7. I will not engage in the use of profanity.
8. I will not encourage my child, or any other person, to engage in the use of profanity.
9. I will treat any coach, parent, player, participant, official or any other attendee with respect regardless of race, creed, color, national origin, sex, sexual orientation or ability.
10. I will encourage my child to treat any coach, parent, player, participant, official or any other attendee with respect regardless of race, creed, color, national origin, sex, sexual orientation or ability.
11. I will not engage in verbal or physical threats or abuse aimed at any coach, parent, player, participant, official or any other attendee.
12. I will not encourage my child, or any other person, to engage in verbal or physical threats or abuse aimed at any coach, parent, player, participant, official or any other attendee.
13. I will not initiate a fight or scuffle with any coach, parent, player, participant, official or any other attendee.
14. I will not encourage my child, or any other person, to initiate a fight or scuffle with any coach, parent, player, participant, official or any other attendee.
I hereby agree that if I fail to conform my conduct to the foregoing while attending, coaching, officiating, or participating in a youth sports event, I will be subject to disciplinary action, including but not limited to the following in any order or combination:
1. Verbal warning issued by Collierville Parks Staff.
2. Written warning issued by Collierville Parks Staff.
3. Suspension or immediate ejection from a youth sports event issued by Collierville Parks Staff.
4. Suspension from multiple youth sports events issued by Collierville Parks Staff.
5. Season suspension or multiple season suspension issued by Collierville Parks Staff.
6. Any other form of disciplinary action as deemed necessary by Collierville Parks Staff.
REFUND POLICY: No refunds will be issued after game schedules have been issued (adult sports), or when rosters have been formed (youth sports). The Town of Collierville does not discriminate on the basis of race, color, national origin, age, sex, or disability in its hiring and employment practices, or in admission to, access to, or operation of its programs, services, and activities pursuant to Title VI of the Civil Rights Act of 1964 (42 U.S. C. 200d) and the Americans with Disabilities Act of 1990, Pub. L 101-336. NOTE: Written request must be submitted to department for a refund prior to program start date. Refund will be submitted to the Name and payment method used at registration.
By signing below, you agree that you have read and understand all of the above.
______
(Signature of Team Manager) (Date)
______
(Printed Name of Team Manager)
FOR OFFICE USE ONLY
Receipt Number: ______
Name on Check: ______
Check No.: ______