2mParks & Recreation Department
South Miami Community Center
305 -668 -7232
DATE: February 10, 2010
TO: Honorable Mayor & Members of City Commission
VIA: Roger M. Carlton, Acting City Manager
FROM: Cesar Garcia, Parks & Recreation Director CT
RE: Travel Basketball Registration Process
South Miami
F l o r i d a
Atl- rice City.
2001
EM
In response to the volunteer basketball coach who expressed his concern about our basketball registration
process, this memorandum should help to clear a few things up. First of all, we have three teams that play
in the Northwest Boys & Girls Club League (NWBGC). The teams are in the following age categories:
U9, U11, & U13. As part of the participation in this league, our teams play against teams from sites such
us Richmond, Tacolcy, Overtown, Gwen Cheery, NWBGC, Coconut Grove, & North Miami to name a
few.
Our teams have historically played in this league and the coach who came to you last meeting has been a
long time coach of this program. This is not his first time registering players for this league or any other
and he is well aware of the process we have in place to have coaches turn in their players' registration
packets. We can be lenient to a certain extent on a few required items for this program if given enough
time. The day in question, I personally asked him if he would have his packets completed in time to
which he assured me that he would. Furthermore, he was given the packets at the same time as the two
other coaches and one of them was able to completely turn his team's infornation in on time. The other
team had an extra day to comply with their paperwork due to their game schedule and they were able to
play their first game without a problem. A driver was available for the team that missed the game,
however, we were not going to put the City of South Miami in harms way by allowing children to play
and be transported in a. City vehicle and by a City staff person, without first assuring that they are
officially included in the program and that he /she are included on our insurance policy. Below is how the
procedure should work. Attached is a copy of the registration packet.
1. Coaches and interested players pick up their participation packets from the front desk.
2. A deadline of at least 48 hours before the first game or practice is given to the coaches to turn in
their completed package with a team roster.
3. Documentation is verified for completeness and accuracy to include parent signatures authorizing
for child participation.
4. Administrative staff contacts the insurance company to make sure that the list of players is placed
on our insurance policy.
5. Children are then allowed to participate in the program.
To assure that this incident does not repeat itself, Site Manager, Worrell Troup, has been put in charge of
the program to include ensuring that registration materials are provided to coaches and participants on
time. Furthermore, we have delegated a Recreation Leader to be in charge of operational details of the
program and another Recreation Leader to handle the Administrative portion. We have also counseled the
Coach advising him that he must do a better job regarding the details of the program.
END OF MEMORANDUM
(t)
CITY OF SOUTH MIAMI
PARKS AND RECREATION DEPARTMENT
FITNESS CENTER MEMBERSHIP REGISTRATION FORM
COMMUNITY CENTER 5800 SW 66 Street
(305) 668 -7232 South Miami, FL 33143
No.
BY COMPLETING AND SIGNING THIS FORM, THE APPLICANT AND ALL INCLUDED FAMILY MEMBERS AGREE TO ABIDE BY
ALL CITY AND DEPARTMENTAL RULES AND REGULATIONS, AND FURTHER AGREE TO INDEMNIFY AND HOLD THE CITY
HARMLESS WITH REGARDS TO ANY INJURIES RECEIVED AS A RESULT OF THE USE OF CITY OF SOUTH MIAMI FACILITIES
AND /OR EQUIPMENT.
Name: Gender:
(Last) (First)
Name of Parent/Guardian (if participant under 18 years old):
Address:
Telephone:
Medical Conditions /Allergies:
Emergency Contact(s):
MEMBERSHIP TYPE
❑ Travel Basketball (e
Shirt Size (circle size)
Shorts Size (circle size)
Shoe Size:
City:
(Names and Phone Numbers)
RESIDENT NON - RESIDENT
ges 9 - 18) ❑ $30.00 ❑ $60.00
Youth - S M L Adult — S M L XL XXL
Youth - S M L Adult — S M L XL XXL
_ G.P.A.:
Check List of Forms
❑ Copy of Latest Report Card ❑ Physical Form (Completed by Physician)
❑ Insurance Form ❑ Copy of Birth Certificate or Passport
GENERAL AGREEMENT / RELEASE
D.O.B.: _ /_ /_ Age:
Amt. Paid
Redd. By
Balance Due
Zip Code:
In consideration for the City of South Miami Parks and Recreation Department providing membership privileges,
I, , do hereby:
(print name)
1) Assume all risk of possible damage or injury through the use of City of South Miami recreational facilities.
2) Agree to compensate the City of South Miami for any repair and /or replacement costs for damages to the
facility or equipment as a result of my misuse of equipment.
3) Agree to indemnify and hold harmless the City of South Miami and /or its departments, agents or employees
from any liability arising out of my use of City of South Miami facilities and /or equipment.
4) Understand and agree to abide by all applicable rules and regulations. I further understand that I may be
asked to leave the premises and may face suspension or termination of membership if I fail to abide by these
rules and regulations or any other reasonable request from City of South Miami staff.
5) Certify that the participant named herein is in normal health. I understand that the City of South Miami only
carries secondary health insurance and that my insurance bears primary responsibility for any illness or injury
that occurs as a result of participation in this activity. I further give my permission for emergency medical
treatment to be administered when necessary. I agree I am financially responsible for any such treatment.
Signature: Date:
Parent or Legal Guardian (if Participant under 18 years old)
Parks & Recreation Official: Title: Date:
City of South Miami
Parks & Recreation Department South Miami
5800 SW 66"Street AID ame�r9cacity
South Miami, Florida 33143
(305) 668 -7232
2001
Travel Basketball Criteria - Players
1. Player must have a 1.9 G.P.A. or higher before the start of the season.
2. The most recent report card must be presented for verification of grades
along with a recent picture (head shot) of the potential player.
3. An accurate birth certificate must be presented before the start of the
season.
4. Player must not have excessive disciplinary infractions at his /her school of
study.
5. Player must be of age to play on his or her desired team and cannot exceed
the specific team's grade or age of participation.
6. Player must have satisfactory home behavior and full parental permission to
participate in this program which includes occasional travel throughout the
state from April to August. Such permission must be certified by parent
signature below.
7. Player understands that he /she and their teammates will be responsible to
fundraise the necessary amounts for each tournament the team participates
in two weeks prior to each deadline.
Your signature below certifies that you and your family will abide by all the above
mentioned prerequisites in order to be granted the opportunity to play with the
South Miami Grey Ghosts Travel Basketball Program.
Print Name
Player's Signature
Head Coach's Signature
Parks & Recreation Supervisor Signature
Date
Date
Date
E�2
JMJW Florida High School Athletic Association
MF Prepartieipation Physical Evaluation (Page 1 of 2) Revised 4/06
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
Part 1. Student Information (to be completed by student or parent).
Student'sName:
Sex:
Age:_ Date ofBirth:_ /_ /_
School: GradeinSchook_ Sport(s):
HomeAddress: HomePhone: ( )
Name ofluarenb'Cuardian: _.
PersontoContactin CaseofEmergency:
RelationshiptoSNdent: HomePhoneNumber(_) WorkPhoneNumber(_)
Personal/FamilyPhysician: City/State: OfficePlione:(_)
Part 2. Medical History (to be completed by student or parent). Explain "yes" answers below. Circle questions you don't know answers to.
1. Have you had a medical illness or injury since your last check up or
sports physical?
2. Do you have an ongoing chronic illness?
3. Have you ever been hospitalized overnight?
4. Have you ever had surgery?
5, Are you currently taking any prescription or nonprescripti on (overy
the- counter) medications or pills or using an whaler?
6. Have you ever taken arty supplements or vitamins to help you gain or
lose weight or improve your performance?
7. Do you have any allergies (for example, to pollen, medicine, food, or
stinging insects)?
8. Have you ever had a rash or hives develop during or after exercise?
9. Have you ever passed out during or after exercise?
10. Have you ever been dizzy during or after exercise?
11, Have you ever had chest pain during or after exercise?
12. Do you get tired more quickly thmh your friends do during exercise?
13. Have you ever had racing of your heart or skipped heartbeats?
14. Have you had high blood pressure or high cholesterol?
15. Have you ever been told you have a heart murmur?
16. Has any family member or relative died of heart problems or sudden
death before age 509
17. Have you had a severe viral infection (for example, myocardhis or
mononucleosis) within the last month?
18. Has a physician ever denied or restricted your participation in sports
for any heart problems?
19. Do you have arry current skin problems (for example, itching, rashes,
acne, warts, fungus, or blisters)?
20. Have you ever had a head injury or concussion?
21. Have you ever been knocked out become unconscious, or lost your
memory?
22. Have you ever had a seizme?
21 Do you have frequent or severe headaches?
24, Have you ever had numbness or tingling in your arms, hands, legs, or
feet?
25. Have you ever had a stinger, bumer, or pinched nerve?
Yes No
Yes No
_ 26.
Have you ever become ill from exercising in the heat? _ _
V.
Do you cough, wheeze, or have trouble breathing during or after _
_
activity?
_ 28.
Do you have asdhma? _ _
_ 29.
Do you have seasonal allergies that require medical treatment? _ _
30.
Do you use any special protective or corrective equipment or devices _ _
_
that aren't usually used for your sport or position (for example, knee
brace, special neck roll, foot ordhotics, retainer on your teeth, hearing
_
aid)?
31.
Have you had any problems with your eyes or vision? _ _
32.
Do you wear glasses, contacts, or protective eyewear? _ _
_ 33.
Have you ever had a sprain, strain, or swelling after injury? _ _
_ 34.
Have you broken m fractured any bones ordislocated anyjoints? _
35.
Have you had any other problems with pain or swelling in muscles, _ _
_
tendons, bones, orjoints?
ljyes. check appropriate blank and exishnn below.
Head Elbow Hip
_ _ _
Neck Forearm Thigh
_ _
Back Wrist Knee
_ _ _
Chest Hard Shin/Calf
_
Shoulder Finger _ Ankle
Upper Ann _ Foot
_ 36.
Do you want to weigh more or less than you do now?
37.
Do you lose weight regularly to meet weight requirements for year _
_
sport?
38.
Do you feet stressed out? _
39.
Record the dates ofyow most recent immunizations (shots) for:
_
Tetanus: Measles:
Hepatims B. Chickenpox:
FEMALES ONLY (optional)
40.
When was your first menstrual period?
_ 41.
When was you most ecent menstrual period?
42.
How much time do you usually have from the sun of one period to
_
the start of another?
43.
How many periods have you had in the last yam'?
_ 44.
What was the longest time between periods in the last year? _
We hereby state, to the best of am knowledge, that our answers to the above questions are complete mid correct. In addition to the routine medical evaluation required by s,1006.20, Florida
Sutures, mid FHSAA Bylaw 11.8, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assessment, which may include such diagnostic
tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test.
Signature of Smdent.
Date: Sigmmre oftiarenNGuardism
Date:
fj� Florida High School Athletic Association
TF Prepartieipation Physical Evaluation (Page 2 of 2) Revised 4/06
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written below.
Part 3. Physical Examination Ro be completed by ifcensed physk inn, licensed osleapalhic physician, licensed chiropractic pirysidan or certified advanmd registered aurae practitioner).
Student'sName: - DateofBirth: /_ /_
Height: Weight: %Body Fat(optional): Pulse: Blood Pressure:_ /_(_/
Visual Acuity: Right 20/ Left 20% Corrected: Yes No Pupils: Equal Unequal
FINDINGS NORMAL ABNORMAL FINDINGS INITIALS*
MEDICAL
1. Appearance
2. Eyes/Ews/Nose/Throw
3, Lymph Nodes
4, Heart
5, Pulses
6. Lungs
7. Abdomen
8. Genitalia (males only)
9. Skin
MUSCULOSKELETAL
10. Neck
11. Back
11 Shoulder /Arm
13, Elbow/Forearm
14. Wrist/Hand
15. Hip/Thigh
16. Knee
17. Leg /Ankle
18. Foot
* – station -based examination only
ASSESSMENT OF EXAMINING PHYSICIAN/NURSE PRACTITIONER
I hereby certify that each examination listed above was performed by myself or an individual under my direct supervision with the following conclusion(s):
_ Cleared without limitation.
Not cleared for: Reason:
_ Cleared after completing evaluation /rehabilitation for
Referred to For:
Recommendations:
Name of Physician/Nurse Practitioner (print or type): Date:
Address:
Signature of Physician/Nurse Practitioner
ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable)
I hereby certify that the examination(s) for which referred was /were performed by myself or an individual under my direct supervision with the following conclusion(s):
_ Cleared without limitation.
—Not cleared for: Reason:
_ Cleared after completing evaluation/rehabilitation for
Recommendations'.
Name of Physician (print or type):
Address:
Signature of Physician:
Date:
Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Soci-
ety far Sports Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy for Sports Medicine.
–2–
PRIMARY / EXCESS PLANS
100% USUAL & CUSTOMARY
VOLUNTARY BENEFITS
Primary/Excess Insurance - the first $100 of
coverage is Primary - pays without regard to other
Insurance. Benefits over $100 are paid in Excess
of other Insurance.
Maximum $100,000
Deductible None
Accidental Death $5,000
Accidental Dismemberment $10,000
VOLUNTARY RATES
Rates per Participant (Roster Required)
$6.30 Plan:Youth / Primary- Excess / $0 Deductible /
Voluntary
$13.55 Plan: Adult /Primary- Excess /$0 Deductible /
Voluntary
$3.65 Plan: Summer Camp /;Primary- Excess / $0
Deductible / Voluntary
DATES OF INSURANCE
3. Injury received while traveling or flying by air, except as a fare
Your insurance is effective on the latter of the
4. Injury covered by worker's compensation or the occupational
policy effective date; or the date you become
5. Treatment of Illness, disease or infections, except pyogenic
eligible to be included within a class of
Ingestion of contaminated substances.
persons eligible for coverage under the policy.
7. Treatment of Osgood- Schlattees disease; appendicitis,
Your coverage will end on the policy
weakness; hernia; TMJ; fainting; headaches; boils; [bilateral
termination date.
detached retina unless directly caused by injury; or mental or
nervous disorders whether or not caused by injury.
PRIMARY / EXCESS PLANS -
100% USUAL & CUSTOMARY
EXCLUSIONS
This policy does not provide benefits for:
1. Treatment, services or supplies which:
a. Are not medically necessary;
b. Are not prescribed by a doctor as necessary to
treat an Injury;
c. Are determined to be
experimental /investigational in nature;
d. Are received without charge or legal obligation
to pay;
e. Are received from persons employed or retained by
the school or any family member, unless
otherwise specified;
f, Are nor specifically listed as covered charges on
this policy;
2. Intentionally self - inflicted injury, violating or attempting to
violate any duly enacted law. Injury by acts of war, whether
declared or not.
3. Injury received while traveling or flying by air, except as a fare
paying passenger on a regularly scheduled commercial airline.
4. Injury covered by worker's compensation or the occupational
disease law.
5. Treatment of Illness, disease or infections, except pyogenic
infections or bacterial infections which result from the accidental
Ingestion of contaminated substances.
6. Heat exhaustion.
7. Treatment of Osgood- Schlattees disease; appendicitis,
osteomyelitis, pathological [or stress] fractures; congenital
weakness; hernia; TMJ; fainting; headaches; boils; [bilateral
spondylolysis; osteochrondritis; dissecans; poison ivy; bee stings;
detached retina unless directly caused by injury; or mental or
nervous disorders whether or not caused by injury.
8. Injury contributed to by the use of alcohol or drugs not
prescribed by a doctor.
9. Suicide or attempted suicide while sane; or self- destruction or
aSPempt to self- destroy while Insane.
10. Expense incurred for the use of orthotics unless used
exclusively to promote healing.
11. Heart and /or circulatory malfunction resulting from
participation in a covered activity.
12. Any penalty imposed by other valid and collectible insurance
or plan for failure to follow plan procedures.
NOTICE OF CLAIM
In the event of an accident, the recreation organization must be
contacted to obtain an accident claim form. The completed claim
form must be received within 60 days of the date of the injury. This
form must have all sections completed and signed by an official of
the recreation organization and the parent or guardian of the
covered participant.
Forward completed claim form and HCFA -1500 or UB -92 to:
Pearce Administration
P.O. Box 2436
Florence, SC 29503
1- 888 - 722 -1668
�___________________ ------------------------------------------------------------- _--- ___-------------------
REC1 Enrollment Form for Recreation Accident Insurance Program
(Please return to your Recreation Organization along with payment)
NAME OF PARTICIPANT NAME OF PARENT OR GUARDIAN (IF APPLICABLE)
❑ $6.30 * Youth - Ages 18 and Under (all registered participants) ❑ Waiver of Insurance
I do not wish to participate in the Recreation
❑ $13.55 * Adult Sports -Ages 19 and over Accident Insurance program offered through my
participate in sports activities Recreation Organization.
(Except Adult Football)
❑ $3.65 * Summer Camps
payment with this form
Ire of Participant, Parent or Guardian:
Date: