Register Online

All 2018 Spring players will need to fill out and submit ALL FOUR(4) forms
(excluding uniform order form if you do not need one).
In accordance with the State of Michigan and CASL rules and regulations, ALL PLAYERS are required to submit a copy of their birth certificate .
Forms : General Information Form , Medical Release, Parent & Player Concussion information , and Uniform Order Form.

General Information Form

Each Season cost $85 for U9 & U10 and $110 for U11,U12, U13 and U14
Payments can be mailed to 604 N. Catherine St. Lansing MI, 48917
Checks and money orders can be made out to Coach Dan Moreno
There is a $25 late fee for any registrations after Aug 1st.

* Indicates required field

Players Name *

First

Last

Birth Year *

Players School *

Parent / Guardian Name: First , Last *

First

Last

Phone Number *

Address / City / Zipcode *

Email *

ADDITIONAL PARENT INFORMATION

Name : First , Last *

First

Last

Phone Number *

Address / City / Zipcode *

Email *

Submit

MEDICAL RELEASE FORM

As the parent/legal guardian, I request that in my absence the below player be admitted to any hospital medical facility for diagnosis and treatment. I request and authorized physicians, dentist, and staff, duly licensed as Doctors of Medicine Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the below minor. I have not been given a guarantee as to the results of examination or treatment. I authorized the hospital or medical facility to dispose of any specimen or tissue take from the below named player.

* Indicates required field

Player Name *

Date of Birth : Month / Day / Year *

Date of last Tetanus Booster: Month/Day/Year *

Known allergies of this player, including any allergies to medicine : If none, type in none *

Any other medical problems which should be noted: *

Family Physician *

Phone Number *

Name of Parent / Guardian *

Address / City / State / Zipcode *

Phone Number *

Person Responsible for charges ( If different from above ) *

Address / City / State / Zipcode *

Phone Number *

Person to notify if parent / guardian is unavailable *

Phone Number *

Insurance Carrier *

Policy Number *

Signature of Parent / Guardian (Type name in to confirm information is correct on form ) *

Office Use

STATE OF MICHIGAN

COUNTY OF INGHAM

Sworn to and subscribe before me on this day of *

Notary Public in and for the State of Michigan
Commission Expires 5/2020

Submit

PARENT & ATHLETE CONCUSSION INFORMATION SHEET
WHAT IS A CONCUSSION?
A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion
is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.
WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?
Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.
If an athlete reports one or more symptoms of concussion after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury. The athlete should only return to play with permission from a health care professional experienced in evaluating for concussion.
SYMPTOMS REPORTED BY ATHLETE:

Headache or “pressure” in head , Nausea or vomiting , Balance problems or dizziness , Double or blurry vision
Sensitivity to light , Sensitivity to noise , Feeling sluggish, hazy, foggy, or groggy , Concentration or memory problems
Confusion , Just not “feeling right” or is “feeling down”
SIGNS OBSERVED BY COACHING STAFF:
Appears dazed or stunned , Is confused about assignment or position , Forgets an instruction , Is unsure of game, score, or opponent , Moves clumsily , Answers questions slowly , Loses consciousness (even briefly) , Shows mood, behavior, or personality changes , Can’t recall events prior to hit or fall , Can’t recall events after hit or fall

DID YOU KNOW?

Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than adults.

“IT’S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON”

CONCUSSION DANGER SIGNS
In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other , Is drowsy or cannot be awakened , A headache that gets worse ,Weakness, numbness, or decreased coordination , Repeated vomiting or nausea , Slurred speech , Convulsions or seizures
Cannot recognize people or places , Becomes increasingly confused, restless, or agitated , Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)
WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play.
Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, and playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.
Remember: Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?
If an athlete has a concussion, his/her brain needs time to heal. While an athlete’s brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

* Indicates required field

Player Name: First , Last *

First

Last

Players Signature Typed *

Date: Month / Year *

Parent / Guardian Name : First , Last *

First

Last

Parent / Guardian Type Signature *

Date: Month / Year *

JOIN THE CONVERSATION www.facebook.com/CDCHeadsUp
Content Source: CDC’s Heads Up Program. Created through a grant to the CDC Foundation from the National Operating Committee on Standards for Athletic Equipment (NOCSAE). Rick Snyder, Governor James K. Haveman, Director

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