Zachary Junior Broncos Elite Youth Football - Zachary Junior Broncos Elite Youth Football
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Zachary Junior Broncos Elite Youth Football
Zachary Junior Broncos
Elite Youth Football
www.zjbroncos.com
Ralph Walker Jr. President and Head Coach
(504) 234-3095Please fill out and return
Zachary Junior Broncos Elite Youth Football
Registration Information
I would like to thank everyone personally for allowing me this opportunity to coach
your child for the upcoming 2014 football Season. I look forward to a wonderful and
successful football season. I appreciate your continued support.
Thank you,
Ralph J. Walker Jr.
Head Coach B Team
Please make sure all required documents are present at the time of registration. All
forms can be downloaded from the website. A check list is provided to assist with
completion of your packets:
• Completed Registration Packet(Including Ethics form/Parental Agreement form)
• (2) Copies of Birth Certificate
• Physical completed by a Licensed Physician(Due no later than June 2014)
• (2) Recent Color Photos of Child
Zachary Junior Broncos Elite Youth Football (ZJBEYF) is a non-profit
organization that does not discriminate based on color, nationality, orientation,
disability, religion, social economic status, or race. We offer every child the same
opportunity to play in a competitive football League. We welcome all suggestions.
Payments can be mailed or made in person at the open registration. Please visit
the website (www.zjbroncos.com) for the date to be announced. You can mail the
completed packet with full payment of registration fees to:
Zachary Junior Bronco Elite Youth Football
26313 East Meadows Dr.
Jackson La, 70748
Email: zjbfootball@gmail.com
Website: www.zjbroncos.com
Telephone :( 504)234-3095Please fill out and return
Zachary Junior Broncos Elite Youth Football
Parental Agreement
Registration Fee: The Football registration fee for the year 2014 is $ 185.00 per child.
For any additional children of the same family, the registration fee is $165.00 per child.
All fees are non-refundable. We gladly accept cashier checks, and money orders.
Payment plans are also available (payments are non-refundable). Please make all
payments payable to Zachary Junior Broncos Elite Youth Football. Payments can be
mailed or presented in person at the Official Registration, date to be announced.
Payments are due by May 30, 2014.
If a player is registered after this date, additional fees may apply, unless proof of
relocation can be provided. Only cash or money orders will be accepted for late
registration.
The registration payment includes:
• Game day uniforms
• Insurance
• Football Kick-Off F.A.S.T Camp
Parents are responsible for F.A.S.T Camp t-shirts ($15.00),supplying shoulder pads,
a mouth piece, a white helmet with white facemask (logos will be applied by coaching
staff), white practice pants with integrated pads, and black cleats.
Practice jerseys are available at Sports for Life (next to LeBlanc’s grocery store). Please
see the jersey required below (all numbers should be Columbia Blue):
• A Team – White
• B Team – Black
• C Team – Red
• D Team – Red
Referral Acknowledgement: Any members of the ZJBEYF Organization that refer
new members may be eligible for a discounted registration fee. A member is eligible toPlease fill out and return
Zachary Junior Broncos Elite Youth Football
receive $10.00 off of registration when a new member is referred, as well as complete
the registration process (including payment).
Fundraisers: A minimum of one (1) fundraiser will be held during the 2014 Football
Season. All players are required to participate. Children of the same family are
counted as one.
Maintaining Elite Status: All players affiliated with the ZJBEYF Organization, must
maintain a C Average to be eligible to participate in scheduled games. Parents are
required to submit copies of progress reports and reports cards as issued by the school.
Uniform/ Equipment: Each football player’s uniform, for all teams (A, B, C, D) will
include:
• Game day uniform: (2) game jerseys, (1) pair of game pants
• Game belt
• Game day undershirt (Compression shirt available for an additional $20.00)
**Please note additional uniforms can be purchased at your discretion
Risk: Zachary Jr. Broncos Youth Elite Football is a member of the Louisiana River
Parish Youth Football and Cheer League. This is a competitive league and football is a
contact sport. While safety is always our priority, there is always a realistic risk of injury.
These risks exist even with protective equipment. In an effort to minimize injury, full
contact practices will be limited to (3) times a week.
Practices: The first day of official practice will be June 28, 2014. An official
schedule of practices will be distributed and posted on the website.
During the summer, there may be Saturday practices; otherwise all practices will
be held on Monday, Tuesday, Thursday, and Friday starting at 5:30 PM at the
Rollins Street Park (across from Northwestern Elementary). The Head Coach will be
responsible for notifying the ZJBEYF Board and all parents of any changes.Please fill out and return
Zachary Junior Broncos Elite Youth Football
These changes will also be posted on the website. Unexcused absences from
practices will have a negative impact on playing times. It is required that a parent or
guardian be at every practice and game for the entire duration. ZJBEYF will not
be responsible for children left unattended before or after practices and games.
Parental Supervision is required.
Prior to the official start date of practice, Skills Training will be available for all registered
players. Skills Training will be held once per week and is strongly recommended. The
dates of these training will be determined and placed on the ZJBEYF website.
ONLY PLAYERS THAT HAVE COMPLETED REGISTRATION (PAYMENT IN FULL/
PAYMENT PLAN) ARE ELIGIBLE TO ATTEND SKILLS TRAINING.
***The first day for full pads will be August 1, 2014.
Nutrition: Before practice and on game days, it is strongly recommended to provide
your child with a meal containing lots of carbohydrates.
Game Day: Schedules for the upcoming season will be distributed and available via the
ZJBEYF website (www.zjbroncos.com). Please note all home games will be played
at Zachary High School.
Required Participation: In addition to fundraisers, all parents and guardians are
asked to participate in helping during the football season. Each family is asked to select
(2) voluntary slots, one hour in length, to assist with selling of refreshments at the
concession stands or assisting on the field by working the chains.
Concession: The Spirit committee will have the schedule with the time, dates, and
the volunteer assignments. All concession volunteers need to be at least 16 years of
age. All food handlers will be required to use gloves which will be provided by ZJBEYF
organization. Reminders will be sent out prior to each assignment date.
Tobacco/Alcohol: Any parent or guardian caught with tobacco or alcohol during
Louisiana River Parish Youth Football and Cheer League events, games, or practices
will be asked to leave the premises with a possible game suspension of their child andPlease fill out and return
Zachary Junior Broncos Elite Youth Football
are subject to arrest by the Zachary Police Department. We encourage healthy behavior
in our players and ask that all parents and guardians lead by example. Any child caught
with tobacco or alcohol will receive a minimum mandatory one game suspension and
possible removal from the Zachary Junior Broncos Elite Youth Football Organization.
Dismissal/Complaints: If at any time a Head Coach or Board Member feels a child
is in danger or disregarding the team rules and regulations, it can be recommended to
the Executive Board that the child be dismissed. The decision will be formal and will be
decided with a formal hearing. Both sides will be in attendance during this process and
a non-biased mediator will preside over the hearing. Once a decision is made, it will be
FINAL.
** Everyone who is part of The Zachary Junior Bronco Elite Youth Football
organization is expected to behave in a professional manner at all times. Child
(ren), parents, guardian(s) or affiliate(s) who cannot control their temper,
comments, behavior, or actions will be dismissed at the sole discretion of the
board after an appropriate hearing. If found in violation, these individuals will
be dropped from the roster with no further obligation, liability, or consideration.
Formal complaints must be submitted in writing or emailed to the president
within 3 days of the aforementioned incident.
This signature acknowledges that I have received and agree to the Parental
agreement and will adhere to all provisions set forth in this document.
Player’s Name: ________________________________
Parent/Guardian Printed Name: _____________________________________
Parent/Guardian Signature __________________________ Date: _____________Please fill out and return
Zachary Junior Broncos Elite Youth Football
Registration Form
Player’s Information
Child's Name Child’s Age Sex Date of Birth
__________________________ __________ _____ __________________
Permanent Address
______________________________________________________________________
City State Zip Code
__________________________ ________ __________________________
Years of Football Experience Grade Level
_______________________ ___________
School of Attendance
______________________________________________
Does your child have any disability which will require special accommodations?
Yes/No
Does your child have any major medical illness such as Diabetes/Heart conditions?
Yes/NoPlease fill out and return
Zachary Junior Broncos Elite Youth Football
Parental/Guardian Information
Parents/Guardian Full Name Email Address
__________________________________________ ____________________________________
Permanent Address
___________________________________________________________
City State Zip Code
___________________________ _____ ______________
Home Phone Cell Phone
_________________ ____________________
Emergency Contact:
______________________________ ____________________
Name/Relationship Phone Number
Preferred method of contact:
Email/Text/Phone
Are you interested in joining the Coaching Staff? Yes/No
If you were referred by a member, please list the name: _________________________Please fill out and return
Zachary Junior Broncos Elite Youth Football
Ethics and Code of Conduct
Football should be a fun and rewarding time for the players, parents, coaches, officials,
and fans. Through football, Zachary Junior Broncos Elite Youth Football League seeks to
enhance the physical, mental, and emotional well-being of every child that takes part in
this organization. It is the league’s goal that every player will be a better citizen, and have
a greater chance for success in their future endeavors, as a result of their Little League
experience.
In keeping with this philosophy, the following Code of Conduct has been adopted to
promote fairness, teamwork, trust, sportsmanship, responsibility, respect, and discipline
of our players, coaches, parents, and fans.
• To place the emotional and physical wellbeing of all players ahead of personal desires to
win
• To encourage and support all efforts of players on and off the field
• To emphasize good sportsmanship at all times
• To respect all individuals including coaches, officials, parents, and players
• To refrain from unnecessary rudeness, foul language and acts of cruelty at all times
• To instill courtesy, friendliness and kindness in our youth
• To be a team player
• To emphasize that all efforts lead to achievement and respect
• To try their best at all times
Fans/Parents:
• Be a positive role model at all times through your actions and words
• Be a supportive Fan or Parent by showing respect at all times for coaches, players and
fellow fans
• Be mindful and respectful of the coaching staff by not interfering with the coaching staff’s
instructions before, during, or after a game
• Maintain a professional decorum and understand that everyone makes mistakes and
give all the chance to correct those mistakes
• To teach their child they have a responsibility to learn and try their best
• Refrain from rudeness, foul language, belittling and acts of cruelty at all timesPlease fill out and return
Zachary Junior Broncos Elite Youth Football
Parent/Guardian’s Signature __________________________________
Medical History Evaluation Form
LHSAA MEDICAL HISTORY EVALUATION
IMPORTANT: This form must be completed annually, kept on file with the school, and is subject to inspection by the
LHSAA Rules Compliance Team.
PART I: INFORMATION (To be filled out by parent or guardian only)
Name: __________________________________ Grade: ___________ School: ___________________________
Sex: M / F Age: ___ Date of Birth: ________________ Home Telephone #: _____________ Sports: ___________
Address: ____________________________________City:____________________ Zip: _____________________
Parent's Name: _________________Parent's Employer: __________________Work Telephone #:______________
Insurance Company: _________________________Policy #:________ Family Doctor: _______________________
PART II: MEDICAL HISTORY (To be filled out by parent or guardian)
Has or Does this athlete Circle & please explain all "yes" answers below
1. Have a medical problem or injury since his/her last evaluation? ............................................................................................ YES NO
Ever not been allowed to participate in sports for a medical reason? ...................................................................................... YES NO
2. Ever been hospitalized? .......................................................................................................................................................... YES NO
Ever had surgery? ................................................................................................................................................................... YES NO
Have any missing organs? (eye, kidney, testicle, etc.) ............................................................................................................. YES NO
3. Presently take any medication? .............................................................................................................................................. YES NO
4. Have any allergies to medicine or insect bites? ....................................................................................................................... YES NO
5. Passed out during or after exercise? ....................................................................................................................................... YES NO
Been dizzy or passed out during or after exercise? .................................................................................................................. YES NO
Have chest pain during or after exercise? ............................................................................................................................... YES NO
Tire more quickly than his/her friends during exercise? .......................................................................................................... YES NO
Have high blood pressure? ..................................................................................................................................................... YES NO
Been told he/she has a heart murmur? .................................................................................................................................... YES NO
Have racing of the heart or skipped heartbeats? ..................................................................................................................... YES NO
Have a family member that died of heart problems or sudden death before age 50? ........................................................... YES NO
6. Have any skin problems? ........................................................................................................................................................ YES NOPlease fill out and return
Zachary Junior Broncos Elite Youth Football
7. Ever had a head or neck injury? ............................................................................................................................................. YES NO
Ever been knocked out or unconscious? ............................................................................................................................... YES NO
Ever had a seizure? ................................................................................................................................................................ YES NO
Ever had a stinger, burner or pinched nerve? ........................................................................................................................... YES NO
8. Ever had heat cramps? ........................................................................................................................................... YES NO
Ever been dizzy or passed out in the heat? .................................................................................................................................. YES NO
9. Have trouble with breathing or coughing during or after activity? ............................................................................................... YES NO
10. Use any special equipment? (pads, braces, neck rolls, eye guards, kidney belt, etc.) ............................................................ YES NO
11. Have any problems with vision? ............................................................................................................................................ YES NO
Wear glasses or contacts? ....................................................................................................................................................... YES NO
12. Ever sprained/strained, dislocated, fractured or had repeated swelling of any bones or joints? ............................................ YES NO
13. Have any medical problems listed below? (Please check off)
______High Blood Pressure ___________ Rheumatic Fever ___________ Diabetes _________Hepatitis ________Mononucleosis
_____ Abnormal Bleeding ______Tuberculosis _______Asthma ________Sickle Cell Disease/Trait
________Other (list) ___________________________________________________________________________________________
14. List dates for last: Tetanus Shot: _____________________ Measles Immunization: ___________________________________
15. Female athletes, list dates for: First menstrual period: _________________________ Last menstrual period: ______________________
Longest time between periods last year: _________________________________________
Please explain all "yes" answers from above: _______________________________________________________________________________
____________________________________________________________________________________________________________________
PART III: SIGNATURES
(You must answer these questions and sign for your child to be examined)
1. The information on the reverse is current and correct to the best of my knowledge…................................................................ YES NO
2. I give my permission for my child to be examined for school-related activities.................................................................... YES NO
3. If, in the judgment of a school representative, the named student athlete needs care or treatment as a result of an injury or sickness,
I do hereby request, consent and authorize for such care as may be deemed necessary....................................... YES NO
4. I recognize the evaluation to be done on my child is a standard pre-participation screening examination, and that no in-depth testing,
x-rays, lab work, or cardiac testing will be performed..................................................................... YES NO
5. I understand that if the medical status of my child changes in any significant manner after his/her physical examination,
I will notify his/her principal of the change immediately.................................................................................. YES NO
6. I give my permission for the athletic trainer to release information concerning my child’s injuries
to the head coach/athletic director/principal of his/her school. .......................................................................................................... YES NO
Signature of Parent/Guardian: __________________________________________________ Date: _______________________________________Please fill out and return
Zachary Junior Broncos Elite Youth Football
Signature of Student Athlete: ___________________________________________________ Date: ________________________________________
PART IV: PHYSICAL (To be filled out annually by a licensed physician /licensed nurse practitioner in collaboration with doctor or a licensed
physician’s assistant under the supervision of a licensed physician.)
Height Weight Blood Pressure / Pulse
L
SYSTEM NORMAL ABNORMAL INITIALS COMMENTS
I
M Heart
I
Lung
T
E Other
D
Abdominal
C Genitalia
O
M Neck
P Shoulder
L
E Elbow
T
Wrist
E
Hand
Back
Knee
Ankle
Foot
Eye Right 20/ Left 20/ Corrected? Yes/No
CLEARANCE: __________A. Cleared
__________B. Cleared after further evaluation/treatment
__________C. Not cleared for: _________ Collision ___________ Contact ____________Non-contact
RECOMMENDATIONS: ____________________________________________________________________________________________________
__________________________________________________________________________
NAME OF MD/NURSE PRACTITIONER: ___________________________________DATE: _____________________________
ADDRESS: _____________________________________TELEPHONE:__________________________________________
SIGNATURE OF MD/NURSE PRACTITIONER: __________________________________________________________________________________________________You can also read
