2024 Bernard Blackwell All-Star Football Acceptance | Mississippi Coaches Association: Online Forms

PLAYER/MANAGER PERSONAL INFORMATION

Name (as you would like it to appear in the Program Book)*

First Last

High School*

Mailing Address*

Street Address City State ZIP Code

Example:
Street: 1 Main St
City: Anytown
State: Mississippi
Zip: 12345

Home Phone*

Cell Phone*

Player Email*

School Mascot*

High School Coach

First Last

PLAYER/MANAGER AGREEMENT

Agreement*

I accept the invitation to participate in the 2024 Bernard Blackwell Classic All-Star Football game directed by the Mississippi Association of Coaches, and agree to:

Follow all the rules and regulations of the host school and the Mississippi Association of Coaches;

Notify the Association immediately if circumstances change affecting my decision or ability to participate, so that an alternate can have the chance to participate and receive full benefits and honors;

By accepting this invitation I pledge my full support to my team and coaches and agree to accept all the responsibilities which go along with the honor. These responsibilities include:

• Meeting all deadlines

• Supplying requested information (deadline October 9)

• Reporting on time

• Fundraising through Vertical Raise.

Consent to being contacted by Vertical Raise regarding the All-Star Fundraiser
I will not be able to participate in the 2024 Bernard Blackwell All-Star Football Classic.

Photography Release*

Yes- I give the Mississippi Association of Coaches and its assigns, licensees and legal representatives the irrevocable right to use any picture or image or sound recording of the student in all forms and media and in all manners, for any lawful purposes. In addition, I consent to the disclosure, by my child’s/ward’s school, to the MAC, upon its request, of all records relevant to his/her eligibility and participation including, but not limited to, his/her records relating to enrollment and attendance, academic standing, age, discipline, residence and physical fitness.
No- I DO NOT give the Mississippi Association of Coaches and its assigns, licensees and legal representatives the irrevocable right to use any picture or image or sound recording of the student in all forms and media and in all manners, for any lawful purposes. In addition, I consent to the disclosure, by my child’s/ward’s school, to the MAC, upon its request, of all records relevant to his/her eligibility and participation including, but not limited to, his/her records relating to enrollment and attendance, academic standing, age, discipline, residence and physical fitness.

I will be playing for:*

NORTH
SOUTH

SIZE INFORMATION

Height

Weight*

Game Pants Size*

Shorts Size*

T-Shirt*

Honors

Please list all honors received in sports and other school activities, and be specific. List the honor and the year, and if the award is not from your school, list the organization giving you the award and the name of the award (i.e., Hattiesburg Optimist Club Student of the Year, 2024).

Honor

Year

Honor

Year

Honor

Year

Honor

Year

Honor

Year

Honor

Year

Honor

Year

Honor

Year

Honor

Year

Where do you plan to attend college?*

What do you plan to major in at college?*

CONSENT TO MEDICAL TREATMENT

Player Name*

First Last

Date of Birth*

Age*

Do you have a current physical on file with your school?*

Yes
No

Parent/Guardian #1*

First Last

Parent/Guardian #1 Email*

Parent/Guardian #1 Phone*

Parent/Guardian #2

First Last

Parent #2 Email

Parent/Guardian #2 Phone

Family Physician*

First Last

Physician Home Phone*

Physician Office Phone*

I/We am/are the athlete's*

Parent(s)
Guardian
Conservator

Part I*

I/We am/are the parent(s) of the athlete listed above and state that he/she has no guardian or conservator appointed by law.

Part I*

I/We am/are the guardian/conservator of the athlete listed above as appointed by law.

Part II*

I/We in the same capacity as indicated in Part I authorize the Mississippi Association of Coaches to take whatever medical steps are deemed necessary in case of injury and/ or illness (including giving authorization to duly qualified medical personnel to administer such medical or surgical treatment to include anesthetics and/or drugs as the duly qualified medical personnel deem necessary in the diagnosis and treatment) of the athlete list above during his/her participation in the 2024 Bernard Blackwell All-Star Football Classic from December 18-21, 2024. Treatment of any such injury and/or illness shall begin immediately upon its discovery.

Part III

Insurance Coverage*

The Above named participant is covered by hospitalization insurance.
The Above named participant is not covered by hospitalization insurance.

Policy #:*

Name of Insurance Company*

Address of Insurance Company*

Street Address City State ZIP Code

If Group Policy, give Employer

Group #

EMERGENCY CONTACT

Name of the closest relative or friend to be contacted in case of emergency if parents/guardian cannot be reached.

Emergency Contact*

First Last

Relationship*

Home Phone*

Cell Phone*

Business Phone

Does your son have any Unusual Health Conditions:

Select all that apply:

Diabetes
Heart Condition
Convulsive Seizures
Allergies
Other
None

'Other' Please list:*

Please list Allergies:*

In case of emergency, Game Committee is authorized to:*

Select all that apply:

Call above named Doctor
Call team doctor if family doctor is not available
Take athlete to local hospital
Other

PLAYER/MANAGER GENERAL RELEASE

We, the undersigned parent(s) or legal guardian(s) of the participant listed above ___________________________________________ (hereinafter “Player”), a member of the 2024 Bernard Blackwell All-Star Football Classic Team for in the consideration of our son to participating in such game hosted by the Mississippi Association of Coaches from December 18 through December 21, 2024, do hereby release the Mississippi Association of Coaches, its officers, directors, members and any other agents or representatives (hereinafter “Releasees”) and hereby hold harmless the Releasees against any and all claims, causes of action, demands, costs, expenses, or any other potential actions asserted arising out of or in any way related to or connected with the participation of our son in the 2024 Bernard Blackwell All-Star Football Classic. We, the undersigned, release the Releasees from any and all claims that may result either from the participation in practices leading up to the 2024 Bernard Blackwell All-Star Football Classic or participation in the game, and transportation to or from the game. Moreover, we do hereby grant permission to the Mississippi Association of Coaches to entertain the above named player during the All-Star week beginning Wednesday, December 18, 2024 until Saturday, December 21, 2024, at the close oft he All-Star activities at Gulfport High School Stadium, Gulfport, MS. We, the under- signed, release the above named parties, their agents, employees and other related persons, including all other Releasees, from any and all claims which may result from the travel and entertainment of the above named player.

We also agree that the released parties shall not be responsible for any illness, disease, injury or other occurrence suffered by the player associated with his travel, entertainment, participation in practice or in the game, and furthermore agree that there shall be no liability to the Releasees herein for any of the above noted acts.

By these presents and in consideration above enumerated, we further covenant and agree that we shall forever re- frain from instituting any action, pressing, collecting or in any way aiding or proceeding upon any and all claims, causes of action, suits and proceedings of any kind at law or in equity which our son or the undersigned ever has, or may have, against any of the Releasees herein arising out of the aforesaid activities, and more particularly participation in practices and the game relating to the 2024 Bernard Blackwell All-Star Football Classic, or any other activity relating thereto.

Acknowledgement*

WE ACKNOWLEDGE THAT WE HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND WE SIGN THE ABOVE AND FOREGOING OF OUR OWN FREE ACT.

STATEMENT OF UNDERSTANDING & NOTICE OF INSURANCE COVERAGE

I, the undersigned parent(s) and/or guardian(s) of the participant named above, a participant in the 2024 Bernard Blackwell All-Star Football Classic, do understand that the insurance coverage provided for all the participants in this game is known as secondary coverage. This specifically means that my personal insurance company’s policy is the primary coverage for my son and will be considered primary in the event my son suffers an accidental injury requiring medical attention, evaluation and/or treatment during any All-Star Activities from December 18, 2024 to December 21, 2024.

I further understand that the Mississippi Association of Coaches does provide insurance coverage to my son, but such coverage is secondary, specifically meaning that such coverage only becomes applicable after my coverage, if any, has first been utilized to cover the expenses and fees for such medical treatment. Moreover, I have been informed that the coverage provided by the Mississippi Association of Coaches may have certain deductions, exclusions and upper limits so as not to provide full coverage to my son even if the insurance is utilized after exhausting my personal coverage, if any.

I further understand that the Mississippi Association of Coaches provides such coverage for the benefit of the participants in the 2024 Bernard Blackwell All-Star Football Classic and their parents, and such insurance coverage possibly may not cover all bills, expenses and other costs incurred by the participants while participating in the 2024 Bernard Blackwell All-Star Football Classic at Gulfport High School Stadium, Gulfport, MS. Toward that end, I have been placed on notice by the Mississippi Association of Coaches and its representatives that if additional insurance coverage is needed for my son, I should provide such insurance at my own expense. I hereby state that the information provided on the Medical Consent form is the correct name, address and policy number of the present health, accident and hospitalization insurance providing coverage for my son. If such coverage is changed, lapses or terminates for any reason, I hereby agree to update and supplement the information provided and to ensure that the Mississippi Association of Coaches and its representatives are provided with current information relating to insurance up and through the date of the game.

Attestation*

I hereby state that the information provided on the Medical Consent form is the correct name, address and policy number of the present health, accident and hospitalization insurance providing coverage for my son. If such coverage is changed, lapses or terminates for any reason, I hereby agree to update and supplement the information provided and to ensure that the Mississippi Association of Coaches and its representatives are provided with current information relating to insurance up and through the date of the game.

SIGNATURES

Date

Player Signature*

Parent #1 Signature*

Parent #2 Signature

Guardian Signature*

2024 Football- Bernard Blackwell All-Star Football Acceptance

PLAYER/MANAGER PERSONAL INFORMATION

PLAYER/MANAGER AGREEMENT

SIZE INFORMATION

Honors

CONSENT TO MEDICAL TREATMENT

Part III

EMERGENCY CONTACT

PLAYER/MANAGER GENERAL RELEASE

STATEMENT OF UNDERSTANDING & NOTICE OF INSURANCE COVERAGE

SIGNATURES