2021 Parental/Guardian Permission and Waiver
Participant Name:
1. PERMISSION: I am the parent or legal guardian of the above-named participant. I acknowledge that my child is in good health. I give permission 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. I give
permission for, and assume any and all risk of my child's use of various playing surfaces including natural and artificial grass, hard dirt, and under varying conditions,
including, dry, wet and muddy, and I hereby understand that any surface may be regular or irregular.
2. RISK INFORMATION: I acknowledge the potential dangers of participation in any sport and I understand that participation in football, cheerleading and/or dance
may result in BODILY INJURY, PARALYSIS, BRAIN INJURY, PERMANENT DISABILITY AND/OR DEATH. I acknowledge that protective equipment does
not prevent all participant injuries, and therefore I release, absolve, indemnify, hold harmless and waive any claim against 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 my child to and from
activities, for any injury to my child whether the result of negligence or for any other cause.
3. EMERGENCY MEDICAL AUTHORIZATION: I give permission for emergency medical/dental treatment or first aid to be administered to my child for any
illness/injury/accident resulting from participation in Pop Warner activities.
4. EQUIPMENT RESPONSIBILITY: I acknowledge my responsibility for any and all equipment/uniforms loaned to my child and I agree to promptly return, upon
request, the uniform and other equipment in good condition except for normal wear and tear. If I fail to comply, I will be responsible for the cost of such
equipment/uniform.
5. INSURANCE DISCLOSURE: I am aware that my local Pop Warner organization carries group accident medical insurance which is secondary or excess to my
insurance which is considered primary insurance. Further, I agree to notify in writing my head coach and local Pop Warner organization of any medical claim from
participation in Pop Warner as soon as reasonably possible. I understand that the registration fee is not premium for insurance and that deductibles may apply.
6. SCHOLASTIC FITNESS: I confirm that 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. Further, I authorize my child’s school to release grades, report cards, and all other scholastic information to the local Pop
Warner organization in order to comply with scholastic fitness requirements.
7. FINANCIAL RESPONSIBILITY: I acknowledge that my rights, if any, to a refund depends on the local Pop Warner 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. COMMUNICATIONS, PROMOTIONS, AND CONSENT: As a condition to my child’s participation, I consent to receive communications by email and mail
from Pop Warner Little Scholars, Inc. and its sponsors. I understand that Pop Warner Little Scholars does not sell its contact list. Communications may contain program
information or special offers. I may “opt out” by instruction in the communication or by my written request to the Pop Warner National Office. Further, I grant Pop Warner
the right and permission to make, reproduce, broadcast or otherwise use in perpetuity my child’s name and likeness including photograph, films, videos, recordings, or
other depictions or images in any form or media throughout the universe, for promotional material, advertising, editorial, trade or other purpose. To the extent that any
benefit may accrue therefrom, I forever waive any interest in or claim to such benefit 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 understand that it is my responsibility to comply with all rules and regulations of Pop
Warner Little Scholars Inc and its affiliated organizations and understand that non-compliance may be cause for discipline and/or dismissal of my child, myself, and/or
other persons affiliated with me or my child. I further understand that my child must meet Pop Warner age and/or weight requirements on their official certification date
as established by Pop Warner without exception and that the decision of the Weigh Master is final. I agree to furnish an authentic certified copy of my child’s birth
certificate 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 in Pop Warner activities. I hereby hold Pop Warner harmless of any financial loss as the result of any
disciplinary action.
11. DISPUTE RESOLUTION POLICY SEVERABILITY: I understand and acknowledge that all disputes with Pop Warner and all affiliated parties will be subject
to binding arbitration in Langhorne, PA in accordance with Pennsylvania law. I hereby agree that this binding arbitration shall be in lieu of any litigation. I also
understand and agree that if I contest any decision or ruling of Pop Warner 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, the reminder shall remain in full force and effect.
In consideration of participation in Pop Warner activities and by my signature below, I confirm 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.
Signature of Parent/Guardian: Print Full Legal Name
Signature of Participant: Print Full Legal Name
Dated: 1/1/2021 PWLS, INC.
