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Youth Impact Program
The Youth Impact Program is a four week mentoring experience that is a result of a partnership with four national universities: Syracuse, Stanford, Tulane, and Houston, the National Football League (NFL), and other stakeholders. Implemented to focus on helping educate urban-based middle school male students, the program is designed to help with issues that face middle school students in inner-city public schools through academic support, guidance counseling, character development, and social interaction activities. Students will also go through extensive football training, taught by leading NCAA and NFL personnel.
The Youth Impact program is a four-week football and academic camp taking place July 5th-July 29th from 9:00 AM to 5:00 PM daily.
The students will meet at their respective school sites between 8:00 and 8:30 AM, and bus over to the Youth Impact Program every morning. While at the camp, students will attend academic and life skill sessions in the morning and early afternoon, and football sessions will take place in the afternoon. Monday - Thursday will consist of this regular schedule, while Fridays will be open for workshops, guest speakers, field trips, and other fun activities.
This is a free program for eligible participants.
Students looking to join the program must meet the following criteria:
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A male student attending one of the programs partnering school sites
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Must currently be going into the 6th grade; 6th going to the 7th grade; or 7th going to the 8th grade (due to NCAA rules, 8th graders proceeding to 9th grade cannot participate)
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Maintain regular school attendance (as specified by the students school)
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Recommended by a school counselor
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Receive a teachers recommendation
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Committed to attending the camp for the duration of the program
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Committed to participating in the year round program
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Must have a physical to attend the camp
The Youth Impact Program is completely free for ALL students that participate.
Student Information
Last Name: _________________________ First Name: __________________________
Address: _________________________________ City: _____________
Zip: ________
Home Phone Number: _____________________
Email: ________________________
School currently attending: ___________________
Grade for fall 2011: __________
Height: _______
Weight: _______
T-shirt YOUTH size: S
M
L
XL
XXL
Athletic Short size:
S
M
L
XL
XXL
Mens Shoe Size: __________
Do you have any football experience? Yes
No
If yes, please explain: ___________________________________________________
Parent/Guardian Information
Contact Name: ___________________________________________________________
Relationship to Student: ____________________________________________________
Home Phone Number: ______________________ Work Phone: ___________________
Cell Phone: _______________________ Email: ________________________________
I, _____________________________, understand that in signing this form I support
_______________________________ (applicants name) in participating in this
academic and full-contact football camp and assume responsibility for their commitment and participation in this program.
Parent/Guardian Signature _______________________________
Date _____________
School Official Sign-off:
I herby confirm that ________________________ meets all the requirements needed to participate in the Youth Impact Program:
_________________________________
______________
__________________
School Official Signature
Date
Contact Number
Teacher Recommendation:
I recommend this student to participate in the Youth Impact program because: __________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________
_________________
Teacher Signature
Date
Student Essay
Please write at least 5 sentences (a paragraph) telling us why you deserve to be selected to attend the NFL Impact Program, and how the program can help you with your future dreams.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
The Youth Impact Program
WAIVER, RELEASE AND INDEMNITY AGREEMENT
We are sorry, but no one will be allowed to participate if the required documents are not received.
NO EXCEPTIONS!!!!!!!!!
RE:
_______________________
Full Name of Participant
Waiver:
IN CONSIDERATION of permission to utilize today and on all future dates, the services, programs, property, staff, equipment and/or facilities offered by
The Youth Impact Program/National Football League/ University
(hereinafter Y.I.P., University and N.F.L.), the Undersigned for him/herself, his/her heirs, executors, administrators, personal representatives or assignees, does hereby release, waive, discharge and covenant not to sue Y.I.P/University/NFL., its owners, members, directors, officers, employees or agents (hereinafter releases) for liability from any and all claims or causes of action, including the negligence of
Y.I.P/University/NFL and/or releases resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to use or observation of, or participation in services, programs, staff, equipment and/or facilities.
_______________________________________
________________________________________
_
Signature of Participant
Date
Signature of Parent/Guardian of Minor
Date
Assumption of Risks:
Physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries.
Y.I.P/University/NFL
provides instruction and direction involving running, jumping, balancing and exertions of strength using various muscle groups, some involving quick movements, speed and change of direction, and others involving sustained physical activity which may place stress on the cardiovascular system. The foregoing and following are intended to be representative but not exhaustive descriptions of the types of risk that may be associated with participation in the activities described herein.
The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises and sprains to 2) major injuries such as joint or back injury, concussion, broken bones or 3) catastrophic injuries including paralysis and death.
The Undersigned has read the previous paragraphs and knows, understands and appreciates these and other risks that are inherent in the activities made possible by Y.I.P.
The Undersigned hereby asserts that participation in said activities is voluntary and that the Undersigned knowingly assumes all such risks.
Indemnification and Hold Harmless:
The Undersigned, for him/herself, his/her heirs, executors, administrators or assigns also agrees to indemnify and save and hold harmless the releasees and each of them from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorneys fees brought as a result of involvement with Y.I.P/University/NFL and/or releases as described herein and to reimburse them for any such expenses incurred.
Severability:
The Undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the laws of the States of New York, California, Louisiana, or Texas and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding:
The Undersigned acknowledges that he/she has read this waiver of liability, assumption of risk and indemnity agreement, fully understands its terms, and understands that he/she is giving up substantial rights, including the right to sue.
The Undersigned further acknowledges that he/she is signing the agreement freely and voluntarily, and intends by his/her signature below, a complete and unconditional release of all liability to the greatest extent allowed by law.
_______________________________________
Name of Participant
___________________________________ __
__
___________________________________ __
Print Name of Parent/Guardian
Date
Signature of Parent/Guardian
Date
FOR THE PARENTS OR GUARDIANS OF MINORS
:
I as parent or guardian of the above named minor hereby give my permission for my child or ward to participate in the above named activity, and further agree, individually and on behalf of my child or ward, to the terms above.
I grant permission to any representative of Y.I.P/University/NFL to act on my behalf in allowing qualified medical personnel, including Y.I.P/University/NFL representatives to give needed (emergency) care to my minor child or ward in the event I am not available for immediate consultation.
________________________________________
Parent Signature
Date
CAMP PHYSICAL FORM
Campers will not be permitted to participate in any camp activities without a current (within a year of start of camp) physical form signed by a doctor or a school nurse.
A current school physical form will be accepted, although please send a copy as we cannot return it
FOR MEDICAL STAFF ONLY
TO BE COMPLETED AND SIGNED BY PHYSICIAN OR SCHOOL NURSE
_________________________ has been examined by me on ______________________ and has been found in satisfactory health and free of disease. There are no apparent contra-indications to participating in football camp activities.
PHYSICIANS SIGNATURE____________________________________________________________
ADDRESS______________________________________________________________
TELEPHONE____________________________________________________________
CAMPERS NAME__________________________________________________________________
LOCATION (circle one): STANFORD SYRACUSE
TULANE HOUSTON
DATE OF BIRTH______________
HEIGHT _____________
WEIGHT _________
BLOOD PRESSURE____________
Has the camper ever been diagnosed with or treated for any of the following conditions? If so, please check all that apply:
SICKLE CELL TRAIT _____
HEART CONDITION _____
ASTHMA _____
DIABETES ______
EPILEPSY ______
OTHER ______
ALLERGY (food, medication, other, please list):________________________________
MEDICATIONS (please list those that will be taken during camp):________________________________
IMMUNIZATION RECORDS (confirm that campers are immunized for the following):
Diptheria ___ Mumps ___ Tetanus ___ Rubella ___ Polio ___ Measles ___ Pertussis ___
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