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SAN MATEO NATIONAL LITTLE LEAGUE BASEBALL
2017 ASAP Last Revision: March 10, 2017
50/70, Majors, AAA, AA, A, T-Ball and Wiffle Ball Divisions
Page 2 of 88 TABLE OF CONTENTS
1.0 Safety Officer and Safety Manual 2.0 Safety Manual Distribution 3.0 Emergency and Key Official Contacts 4.0 Volunteer Application Form 5.0 Fundamentals Training 6.0 First Aid Training 7.0 Coaches/Umpire to Walk Field Before Use 8.0 2017 Annual Little League Facility Survey 9.0 Safety Procedures for Concession Stand 10.0 Regular Inspection and Replacement of Equipment 11.0 Accident Reporting and Tracking 12.0 First-Aid Kits 13.0 San Mateo National Little League Local Rules 16.0 National Background Screening
3 3 3 3 5 27 49 48 52 54 55 70 71 73
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1.0
SAFETY OFFICER
The San Mateo National Little League Safety Officer is: Gary S. Koe and is on file with Little League headquarters. Contact information: e-mail:
[email protected] phone: (650) 522-8252 2.0
SAFETY MANUAL DISTRIBUTION
San Mateo National Little League will distribute a paper copy of this safe manual to all managers/coaches, league volunteers and the district administrator. 3.0
EMERGENCY INFORMATION AND KEY OFFICIAL CONTACTS
SMNLL HOME: LAKESHORE PARK / MARTEN’S FIELD 1500 Marina Court, San Mateo, CA 94403 Emergency Phone Number:
911
Local Police Non- Emergency
(650) 522-7770
Local Fire Emergency
(650) 522-7360
League President
Paul Willerup
(415) 336-3093
League Vice President
Jerry Berkson
(650) 483-3616
League Maintenance
Paul Willerup
(415) 336-3093
League Safety Officer
Gary Koe
(650) 533-8252
This information will be posted in the concession area and dugout area 4.0
VOLUNTEER APPLICATION FORM
The San Mateo National Little League uses the Official Little League volunteer application form shown in Figure 1. This form is used in conjunction with First Advantage to perform background checks on SMNLL managers/coaches, board members and volunteers that have repetitive interactions with players.
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Little League Volunteer Application -2017 ®
Do not use forms from past years. Use extra paper to complete if additional space is required. A COPY OF VALID GOVERNMENT ISSUED PHOTO IDENTIFICATION MUST BE ATTACHED TO COMPLETE THIS APPLICATION. Name __________________________________ Date ___________________ Address ________________________________________________________ City ____________________________ State _________Zip _____________ Social Security # (mandatory with First Advantage or upon request) _______________ Cell Phone Business Phone Home Phone: E-mail Address: Date of Birth ____________________________________________________ Occupation _____________________________________________________ Employer _______________________________________________________ Address ________________________________________________________ Special professional training, skills, hobbies: ___________________________ Community affiliations (Clubs, Service Organizations, etc.): Previous volunteer experience (including baseball/softball and year):
Please list three references, at least one of which has knowledge of your participation as a volunteer in a youth program: Name/Phone
AS A CONDITION OF VOLUNTEERING, I give permission for the Little League organization to conduct background check(s) on me now and as long as I continue to be active with the organization, which may include a review of sex offender registries (some of which contain name only searches which may result in a report being generated that may or may not be me), child abuse and criminal history records. I understand that, if appointed, my position is conditional upon the league receiving no inappropriate information on my background. I hereby release and agree to hold harmless from liability the local Little League, Little League Baseball, Incorporated, the officers, employees and volunteers thereof, or any other person or organization that may provide such information. I also understand that, regardless of previous appointments, Little League is not obligated to appoint me to a volunteer position. If appointed, I understand that, prior to the expiration of my term, I am subject to suspension by the President and removal by the Board of Directors for violation of Little League policies or principles. Applicant Signature _______________________________________ Date _________
Do you have children in the program? Yes No If yes, list full name and what level? _____________________________________________________ Special Certification (CPR, Medical, etc.): ______________________________ Do you have a valid driver’s license: Yes No Driver’s License#: ________________________________State ___________ Have you ever been convicted of or plead guilty to any crime(s) involving or against a minor?: Yes No If yes, describe each in full:_________________________________________ Are there any criminal charges pending against you regarding any crime(s) involving or against a minor? Yes No If yes, describe each in full:______________ Have you ever been refused participation in any other youth programs? Yes No If yes, explain: ___________________________________________________ In which of the following would you like to participate? (Check one or more.) League Official Coach Umpire Field Maintenance Manager Scorekeeper Concession Stand Other
If Minor/Parent Signature___________________________________Date __________ Applicant Name(please print or type) _______________________________________ NOTE: The local Little League and Little League Baseball, Incorporated will not discriminate against any person on the basis of race, creed, color, national origin, marital status, gender, sexual orientation or disability.
LOCAL LEAGUE USE ONLY: Background check completed by league officer ________________________________ on ____________________________________________________________________ System)s) used for background check (minimum of one must be checked): Sex Offender Registry
Criminal History Records
*First Advantage
*Please be advised that if you use First Advantage and there is a name match in the few states where only name match searches can be performed you should notify volunteers that they will receive a letter directly from LexisNexis in compliance with the Fair Credit Reporting Act containing information regarding all the criminal records associated with the name, which may not necessarily be the league volunteer.
Only attach to this application copies of background check reports that reveal convictions of this application. 1-02-11-VOLUNTEER APPLICATION 3/28/11
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5.0
FUNDAMENTALS TRAINING •
Mandatory training for managers/coaches is conducted each year. This training addresses baseball fundamentals as provided in this section.
•
At least one manager/coach from each team must attend the yearly training.
•
Training for each manager or coach is good for a three year period.
•
Training will be posted on the local website and/or communicated to each team.
•
The training shall be modified to meet local needs of players and their facilities.
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FIRST AID TRAINING •
Mandatory first aid training for managers/coaches is conducted each year. This training addresses the information provided in this section.
•
At least one manager/coach from each team must attend the yearly training.
•
Training for each manager or coach is good for a three year period.
•
Training will be posted on the local website and/or communicated to each team.
•
The training shall be modified to meet local needs of players and their facilities.
•
Due to their training and education, licensed medical doctors, licensed registered nurses, licensed practice nurses and paramedics are exempt from this training.
•
Individuals who have received training from outside courses are NOT exempt.
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A Fact Sheet for COACHES
To download the coaches fact sheet in Spanish, please visit www.cdc.gov/ConcussionInYouthSports Para descargar la hoja informativa para los entrenadores en español, por favor visite www.cdc.gov/ConcussionInYouthSports
THE FACTS • A concussion is a brain injury. • All concussions are serious. • Concussions can occur without loss of consciousness. • Concussions can occur in any sport. • Recognition and proper management of concussions when they first occur can help prevent further injury or even death. WHAT IS A CONCUSSION? Concussion, a type of traumatic brain injury, is caused by a bump, blow, or jolt to the head. Concussions can also occur from a blow to the body that causes the head and brain to move quickly back and forth— causing the brain to bounce around or twist within the skull. This sudden movement of the brain can cause stretching and tearing of brain cells, damaging the cells and creating chemical changes in the brain. HOW CAN I RECOGNIZE A POSSIBLE CONCUSSION?
ny concussion signs or symptoms, such 2. A as a change in the athlete’s behavior, thinking, or physical functioning. Signs and symptoms of concussion generally show up soon after the injury. But the full effect of the injury may not be noticeable at first. For example, in the first few minutes the athlete might be slightly confused or appear a little bit dazed, but an hour later he or she can’t recall coming to the practice or game. You should repeatedly check for signs of concussion and also tell parents what to watch out for at home. Any worsening of concussion signs or symptoms indicates a medical emergency.
April 2013
To help spot a concussion, you should watch for and ask others to report the following two things:
1. A forceful bump, blow, or jolt to the head or body that results in rapid movement of the head.
It’s better to miss one game than the whole season.
Page 46 of 88 SIGNS AND SYMPTOMS 1
SIGNS OBSERVED BY COACHING STAFF Appears dazed or stunned Is confused about assignment or position Forgets an instruction Is unsure of game, score, or opponent Moves clumsily A nswers questions slowly Loses consciousness (even briefly) S hows mood, behavior, or personality changes Can’t recall events prior to hit or fall Can’t recall events after hit or fall
SYMPTOMS REPORTED BY ATHLETE Headache or “pressure” in head Nausea or vomiting Balance problems or dizziness Double or blurry vision Sensitivity to light Sensitivity to noise Feeling sluggish, hazy, foggy, or groggy Concentration or memory problems Confusion Just “not feeling right” or “feeling down”
Adapted from Lovell et al. 2004
WHAT ARE CONCUSSION DANGER SIGNS?
WHY SHOULD I BE CONCERNED ABOUT CONCUSSIONS?
In rare cases, a dangerous blood clot may form on the brain in an athlete with a concussion and crowd the brain against the skull. Call 9-1-1 or take the athlete to the emergency department right away if after a bump, blow, or jolt to the head or body the athlete exhibits one or more of the following danger signs:
Most athletes with a concussion will recover quickly and fully. But for some athletes, signs and symptoms of concussion can last for days, weeks, or longer.
• • • • • • • • • • •
One pupil larger than the other Is drowsy or cannot be awakened A headache that gets worse W eakness, numbness, or decreased coordination Repeated vomiting or nausea Slurred speech Convulsions or seizures Cannot recognize people or places B ecomes increasingly confused, restless, or agitated Has unusual behavior L oses consciousness (even a brief loss of consciousness should be taken seriously)
If an athlete has a concussion, his or her brain needs time to heal. A repeat concussion that occurs before the brain recovers from the first—usually within a short time period (hours, days, weeks)—can slow recovery or increase the chances for long-term problems. In rare cases, repeat concussions can result in brain swelling or permanent brain damage. It can even be fatal.2,3 HOW CAN I HELP ATHLETES TO RETURN TO PLAY GRADUALLY? An athlete should return to sports practices under the supervision of an appropriate health care professional. When available, be sure to work closely with your team’s certified athletic trainer.
Page 47 of 88 Below are five gradual steps that you and the health care professional should follow to help safely return an athlete to play. Remember, this is a gradual process. These steps should not be completed in one day, but instead over days, weeks, or months. BASELINE: Athletes should not have any concussion symptoms. Athletes should only progress to the next step if they do not have any symptoms at the current step. STEP 1: Begin with light aerobic exercise only to increase an athlete’s heart rate. This means about 5 to 10 minutes on an exercise bike, walking, or light jogging. No weight lifting at this point. STEP 2: Continue with activities to increase an athlete’s heart rate with body or head movement. This includes moderate jogging, brief running, moderate-intensity stationary biking, moderate-intensity weightlifting (reduced time and/or reduced weight from your typical routine). STEP 3: Add heavy non-contact physical activity, such as sprinting/running, highintensity stationary biking, regular weightlifting routine, non-contact sportspecific drills (in 3 planes of movement). STEP 4: Athlete may return to practice and full contact (if appropriate for the sport) in controlled practice. STEP 5: Athlete may return to competition. If an athlete’s symptoms come back or she or he gets new symptoms when becoming more active at any step, this is a sign that the athlete is pushing him or herself too hard.
The athlete should stop these activities and the athlete’s health care provider should be contacted. After more rest and no concussion symptoms, the athlete should begin at the previous step. PREVENTION AND PREPARATION Insist that safety comes first. To help minimize the risks for concussion or other serious brain injuries: • Ensure that athletes follow the rules for safety and the rules of the sport. Encourage them to practice good • sportsmanship at all times. Wearing a helmet is a must to reduce • the risk of severe brain injury and skull fracture. –H owever, helmets are not designed to prevent concussions. There is no “concussion-proof” helmet. So, even with a helmet, it is important for kids and teens to avoid hits to the head. Check with your league, school, or district about concussion policies. Concussion policy statements can be developed to include: The school or league’s commitment to • safety • A brief description of concussion Information on when athletes can safely • return to school and play. Parents and athletes should sign the concussion policy statement at the beginning of the season.
Page 48 of 88 ACTION PLAN WHAT SHOULD I DO WHEN A CONCUSSION IS SUSPECTED? No matter whether the athlete is a key member of the team or the game is about to end, an athlete with a suspected concussion should be immediately removed from play. To help you know how to respond, follow the Heads Up four-step action plan: 1. R EMOVE THE ATHLETE FROM PLAY. Look for signs and symptoms of a concussion if your athlete has experienced a bump or blow to the head or body. When in doubt, sit them out! 2. ENSURE THAT THE ATHLETE IS EVALUATED BY AN APPROPRIATE HEALTH CARE PROFESSIONAL. Do not try to judge the severity of the injury yourself. Health care professionals have a number of methods that they can use to assess the severity of concussions. As a coach, recording the following information can help health care professionals in assessing the athlete after the injury: Cause of the injury and force of the hit or blow to the head or body Any loss of consciousness (passed out/ knocked out) and if so, for how long Any memory loss immediately following the injury
Any seizures immediately following the injury N umber of previous concussions (if any) 3. I NFORM THE ATHLETE’S PARENTS OR GUARDIANS. Let them know about the possible concussion and give them the Heads Up fact sheet for parents. This fact sheet can help parents monitor the athlete for signs or symptoms that appear or get worse once the athlete is at home or returns to school. 4. KEEP THE ATHLETE OUT OF PLAY. An athlete should be removed from play the day of the injury and until an appropriate health care professional says they are symptom-free and it’s OK to return to play. After you remove an athlete with a suspected concussion from practice or play, the decision about return to practice or play is a medical decision. REFERENCES 1. Lovell MR, Collins MW, Iverson GL, Johnston KM, Bradley JP. Grade 1 or “ding” concussions in high school athletes. The American Journal of Sports Medicine 2004; 32(1):47-54. 2. I nstitute of Medicine (US). Is soccer bad for children’s heads? Summary of the IOM Workshop on Neuropsychological Consequences of Head Impact in Youth Soccer. Washington (DC): National Academies Press; 2002. 3. Centers for Disease Control and Prevention (CDC). Sports-related recurrent brain injuries-United States. Morbidity and Mortality Weekly Report 1997; 46(10):224-227. Available at: www.cdc.gov/mmwr/ preview/mmwrhtml/00046702.htm.
If you think your athlete has a concussion… take him/her out of play and seek the advice of a health care professional experienced in evaluating for concussion. For more information, visit www.cdc.gov/Concussion.
Page 49 of 88 7.0
COACHES/UMPIRE TO WALK FIELD BEFORE USE •
Coaches/umpires are required to walk the field before use.
•
It is the responsibility of both teams and the umpire to assure that this is performed. •
Repair needed?
Ball Park Repair
Field Back Stop Home Plate Bases Pitching mound Batter’s box (level) Grass Gopher holes, glass, rocks, etc. Sprinklers Uneven surface Infield fence Outfield fence Foul poles Dugouts Fencing Bench Roof Storage Trash can Clean up needed Spectator area Bleachers Handrails Parking
YES
NO
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SAFETY PROCEDURES FOR CONCESSION STAND
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REGULAR INSPECTION AND REPLACEMENT OF EQUIPMENT
•
Manager/coaches to inspect equipment before each use.
•
Notify league equipment manager of any faulty or broken equipment
•
League equipment manager inspects all equipment prior to distribution to teams and replaces as needed. Repair needed?
Equipment Catcher’s equipment Shin guards Helmet and facemask Chest protector Catcher’s mitt Player’s Equipment Batting Helmets Bats
YES
NO
Page 55 of 88 11.0
ACCIDENT REPORTING AND TRACKING
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For Local League Use Only
A Safety Awareness Program’s Incident/Injury Tracking Report
Activities/Reporting
League Name: _____________________________ League ID: ____ - ___ - ____ Incident Date: __________ Field Name/Location: _________________________________________________ Incident Time: __________ Injured Person’s Name: ______________________________________ Date of Birth: ___________________ Address: __________________________________________________ Age: ________ Sex: ❒ Male ❒ Female City: ____________________________State ________ ZIP: ________ Home Phone: (
) _____________
Parent’s Name (If Player): ____________________________________ Work Phone: ____________
) _____________
(
Parents’ Address (If Different): _________________________________ City ___________________________ Incident occurred while participating in: A.) ❒ Baseball
❒ Softball
❒ Challenger
❒ TAD
B.) ❒ Challenger
❒ T-Ball (4-7) (5-8)
(7-11) ❒ Minor (7-12)
❒ Major (9-12)
(50/70) (11-13) ❒ Intermediate Junior (13-14)
Senior (13-16)(16-18) Big League (15-18) ❒ Junior Senior(12-14) (14-16) ❒ Big League C.) ❒ Tryout ❒ Travel to
❒ Practice
❒ Game
❒ Tournament
❒ Special Event
❒ Travel from
❒ Other (Describe): ________________________________________
Position/Role of person(s) involved in incident: D.) ❒ Batter
❒ Baserunner
❒ Pitcher
❒ Catcher
❒ First Base
❒ Second
❒ Third
❒ Short Stop
❒ Left Field
❒ Center Field
❒ Right Field
❒ Dugout
❒ Umpire
❒ Coach/Manager ❒ Spectator
❒ Volunteer
❒ Other: __________________
Type of injury: _____________________________________________________________________________ _________________________________________________________________________________________ Was first aid required? ❒ Yes ❒ No If yes, what:________________________________________________ Was professional medical treatment required? ❒ Yes ❒ No If yes, what: ____________________________ (If yes, the player must present a non-restrictive medical release prior to to being allowed in a game or practice.) Type of incident and location: A.) On Primary Playing Field ❒ Base Path: ❒ Running or ❒ Sliding ❒ Hit by Ball:
❒ Pitched or
❒ Collision with: ❒ Player or
❒ Thrown or ❒ Batted ❒ Structure
B.) Adjacent to Playing Field ❒ Seating Area ❒ Parking Area C.) Concession Area
D.) Off Ball Field ❒ Travel: ❒ Car or ❒ Bike or ❒ Walking
❒ Grounds Defect
❒ Volunteer Worker
❒ League Activity
❒ Other: ____________________________________
❒ Customer/Bystander
❒ Other: ________
Please give a short description of incident: ____________________________________________________ _________________________________________________________________________________________ Could this accident have been avoided? How: __________________________________________________ This form is for local Little League use only (should not be sent to Little League International). This document should be used to evaluate This form is for Little League purposes only, to report safety hazards, unsafe practices and/or to contribute posipotential safety hazards, unsafe practices and/or to contribute positive ideas in order to improve league safety. When an accident occurs, tive ideas in order to improve league safety. When an accident occurs, obtain as much information as possible. obtain as much information as possible. For all Accident claims or injuries that could become claims to any eligible participant under the AcFor allInsurance claims policy, or injuries could becomeNotification claims, please fill out and at turn in the official Little League Baseball cident pleasewhich complete the Accident Claim form available http://www.littleleague.org/Assets/forms_pubs/ Accident Notification Form available from your league president and send to Little League Headquarters in asap/AccidentClaimForm.pdf and send to Little League International. For all other claims to non-eligible participants under the Accident Williamsport (Attention: Dan Kirby, Risk Management Department). Also, provide your District Safety Officer with policy or claims that may result in litigation, please fill out the General Liability Claim form available here: http://www.littleleague.org/Asa copy for District files. All personal injuries should be reported to Williamsport as soon as possible. sets/forms_pubs/asap/GLClaimForm.pdf.
Prepared By/Position: ____________________________________ Signature: _____________________________________________
Phone Number: (_____) _____________ Date: _____________________________
Page 57 of 88 Little League Baseball & Softball ®
CLAIM FORM INSTRUCTIONS
WARNING — It is important that parents/guardians and players note that: Protective equipment cannot prevent all injuries a player might receive while participating in baseball/softball. To expedite league personnel’s reporting of injuries, we have prepared guidelines to use as a checklist in completing reports. It will save time -- and speed your payment of claims. The National Union Fire Insurance Company of Pittsburgh, Pa. (NUFIC) Accident Master Policy acquired through Little League® contains an “Excess Coverage Provision” whereby all personal and/or group insurance shall be used first. The Accident Claim Form must be fully completed, including a Social Security Number, for processing. To help explain insurance coverage to parents/guardians refer to What Parents Should Know on the internet that should be reproduced on your league’s letterhead and distributed to parents/guardians of all participants at registration time. If injuries occur, initially it is necessary to determine whether claimant’s parents/guardians or the claimant has other insurance such as group, employer, Blue Cross and Blue Shield, etc., which pays benefits. (This information should be obtained at the time of registration prior to tryouts.) If such coverage is provided, the claim must be filed first with the primary company under which the parent/guardian or claimant is insured. When filing a claim, all medical costs should be fully itemized and forwarded to Little League International. If no other insurance is in effect, a letter from the parent/guardian or claimant’s employer explaining the lack of group or employer insurance should accompany the claim form. The NUFIC Accident Policy is acquired by leagues, not parents, and provides comprehensive coverage at an affordable cost. Accident coverage is underwritten by National Union Fire Insurance Company of Pittsburgh, a Pennsylvania Insurance company, with its principal place of business at 175 Water Street, 18th Floor, New York, NY 10038. It is currently authorized to transact business in all states and the District of Columbia. NAIC Number 19445.This is a brief description of the coverage available under the policy. The policy will contain limitations, exclusions, and termination provisions. Full details of the coverage are contained in the Policy. If there are any conflicts between this document and the Policy, the Policy shall govern. The current insurance rates would not be possible without your help in stressing safety programs at the local level. The ASAP manual, League Safety Officer Program Kit, is recommended for use by your Safety Officer.
Page 58 of 88 TREATMENT OF DENTAL INJURIES Deferred Dental Treatment for claims or injuries occurring in 2002 and beyond: If the insured incurs injury to sound, natural teeth and necessary treatment requires that dental treatment for that injury must be postponed to a date more than 52 weeks after the date of the injury due to, but not limited to, the physiological changes occurring to an insured who is a growing child, we will pay the lesser of the maximum benefit of $1,500.00 or the reasonable expense incurred for the deferred dental treatment. Reasonable expenses incurred for deferred dental treatment are only covered if they are incurred on or before the insured’s 23rd birthday. Reasonable Expenses incurred for deferred root canal therapy are only covered if they are incurred within 104 weeks after the date the Injury is sustained.
CHECKLIST FOR PREPARING CLAIM FORM 1.
Print or type all information.
2.
Complete all portions of the claim form before mailing to our office.
3.
Be sure to include league name and league ID number.
PART I - CLAIMANT, OR PARENT(S)/GUARDIAN(S), IF CLAIMANT IS A MINOR 1.
The adult claimant or parent(s)/guardians(s) must sign this section, if the claimant is a minor.
2.
Give the name and address of the injured person, along with the name and address of the parent(s)/guardian(s), if claimant is a minor.
3.
Fill out all sections, including check marks in the appropriate boxes for all categories. Do not leave any section blank. This will cause a delay in processing your claim and a copy of the claim form will be returned to you for completion.
4.
It is mandatory to forward information on other insurance. Without that information there will be a delay in processing your claim. If no insurance, written verification from each parent/spouse employer must be submitted.
5.
Be certain all necessary papers are attached to the claim form. (See instruction 3.) Only itemized bills are acceptable.
6.
On dental claims, it is necessary to submit charges to the major medical and dental insurance company of the claimant, or parent(s)/guardian(s) if claimant is a minor. “Accident-related treatment to whole, sound, natural teeth as a direct and independent result of an accident” must be stated on the form and bills. Please forward a copy of the insurance company’s response to Little League International. Include the claimant’s name, league ID, and year of the injury on the form.
PART II - LEAGUE STATEMENT 1.
This section must be filled out, signed and dated by the league official.
2.
Fill out all sections, including check marks in the appropriate boxes for all categories. Do not leave any section blank. This will cause a delay in processing your claim and a copy of the claim form will be returned to you for completion.
IMPORTANT: Notification of a claim should be filed with Little League International within 20 days of the incident for the current season.
LITTLE LEAGUE® BASEBALL AND SOFTBALL ACCIDENT NOTIFICATION FORM INSTRUCTIONS
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Send Completed Form To: Little League® International 539 US Route 15 Hwy, PO Box 3485 Williamsport PA 17701-0485 Accident Claim Contact Numbers: Phone: 570-327-1674
Accident & Health (U.S.)
1. This form must be completed by parents (if claimant is under 19 years of age) and a league official and forwarded to Little League Headquarters within 20 days after the accident. A photocopy of this form should be made and kept by the claimant/parent. Initial medical/ dental treatment must be rendered within 30 days of the Little League accident. 2. Itemized bills including description of service, date of service, procedure and diagnosis codes for medical services/supplies and/or other documentation related to claim for benefits are to be provided within 90 days after the accident date. In no event shall such proof be furnished later than 12 months from the date the medical expense was incurred. 3. When other insurance is present, parents or claimant must forward copies of the Explanation of Benefits or Notice/Letter of Denial for each charge directly to Little League Headquarters, even if the charges do not exceed the deductible of the primary insurance program. 4. Policy provides benefits for eligible medical expenses incurred within 52 weeks of the accident, subject to Excess Coverage and Exclusion provisions of the plan. 5. Limited deferred medical/dental benefits may be available for necessary treatment incurred after 52 weeks. Refer to insurance brochure provided to the league president, or contact Little League Headquarters within the year of injury. 6. Accident Claim Form must be fully completed - including Social Security Number (SSN) - for processing. League Name
League I.D.
Name of Injured Person/Claimant
PART 1
SSN
Date of Birth (MM/DD/YY)
Age
Sex
Female Male Home Phone (Inc. Area Code) Bus. Phone (Inc. Area Code) ( ) ( )
Name of Parent/Guardian, if Claimant is a Minor Address of Claimant
Address of Parent/Guardian, if different
The Little League Master Accident Policy provides benefits in excess of benefits from other insurance programs subject to a $50 deductible per injury. “Other insurance programs” include family’s personal insurance, student insurance through a school or insurance through an employer for employees and family members. Please CHECK the appropriate boxes below. If YES, follow instruction 3 above. Does the insured Person/Parent/Guardian have any insurance through: Date of Accident
Time of Accident AM
Employer Plan Individual Plan
Yes Yes
No No
School Plan Dental Plan
Yes Yes
No No
Type of Injury PM
Describe exactly how accident happened, including playing position at the time of accident:
Check all applicable responses in each column: BASEBALL CHALLENGER (4-18) (5-18) SOFTBALL T-BALL (5-8) (4-7) CHALLENGER MINOR (7-12) (6-12) TAD (2ND SEASON) LITTLE LEAGUE (9-12) INTERMEDIATE (50/70) (11-13) JUNIOR (13-14) JUNIOR SENIOR (12-14)(14-16) SENIOR BIG LEAGUE (13-16)(16-18)
BIG (14-18)
PLAYER MANAGER, COACH VOLUNTEER UMPIRE PLAYER AGENT OFFICIAL SCOREKEEPER SAFETY OFFICER VOLUNTEER WORKER
TRYOUTS PRACTICE SCHEDULED GAME TRAVEL TO TRAVEL FROM TOURNAMENT OTHER (Describe)
SPECIAL EVENT (NOT GAMES) SPECIAL GAME(S) (Submit a copy of your approval from Little League Incorporated)
I hereby certify that I have read the answers to all parts of this form and to the best of my knowledge and belief the information contained is complete and correct as herein given. I understand that it is a crime for any person to intentionally attempt to defraud or knowingly facilitate a fraud against an insurer by submitting an application or filing a claim containing a false or deceptive statement(s). See Remarks section on reverse side of form. I hereby authorize any physician, hospital or other medically related facility, insurance company or other organization, institution or person that has any records or knowledge of me, and/or the above named claimant, or our health, to disclose, whenever requested to do so by Little League and/or National Union Fire Insurance Company of Pittsburgh, Pa. A photostatic copy of this authorization shall be considered as effective and valid as the original. Date
Claimant/Parent/Guardian Signature (In a two parent household, both parents must sign this form.)
Date
Claimant/Parent/Guardian Signature
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For Residents of California: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. For Residents of New York: Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. For Residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. For Residents of All Other States: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
PART 2 - LEAGUE STATEMENT (Other than Parent or Claimant) Name of Injured Person/Claimant League I.D. Number
Name of League Name of League Official
Position in League
Address of League Official
Telephone Numbers (Inc. Area Codes) Residence: ( ) Business: ( ) Fax: ( )
Were you a witness to the accident? Yes No Provide names and addresses of any known witnesses to the reported accident. Check the boxes for all appropriate items below. At least one item in each column must be selected. PART OF BODY INJURY POSITION WHEN INJURED 01 ABDOMEN 01 ABRASION 01 1ST 02 ANKLE 02 BITES 02 2ND 03 ARM 03 CONCUSSION 03 3RD 04 BACK 04 CONTUSION 04 BATTER 05 CHEST 05 DENTAL 05 BENCH 06 EAR 06 DISLOCATION 06 BULLPEN 07 ELBOW 07 DISMEMBERMENT 07 CATCHER 08 EYE 08 EPIPHYSES 08 COACH 09 FACE 09 FATALITY 09 COACHING BOX 10 FATALITY 10 FRACTURE 10 DUGOUT 11 FOOT 11 HEMATOMA 11 MANAGER 12 HAND 12 HEMORRHAGE 12 ON DECK 13 HEAD 13 LACERATION 13 OUTFIELD 14 HIP 14 PUNCTURE 14 PITCHER 15 KNEE 15 RUPTURE 15 RUNNER 16 LEG 16 SPRAIN 16 SCOREKEEPER 17 LIPS 17 SUNSTROKE 17 SHORTSTOP 18 MOUTH 18 OTHER 18 TO/FROM GAME 19 NECK 19 UNKNOWN 19 UMPIRE 20 NOSE 20 PARALYSIS/ 20 OTHER 21 SHOULDER PARAPLEGIC 21 UNKNOWN 22 SIDE 22 WARMING UP 23 TEETH 24 TESTICLE 25 WRIST 26 UNKNOWN 27 FINGER
CAUSE OF INJURY 01 BATTED BALL 02 BATTING 03 CATCHING 04 COLLIDING 05 COLLIDING WITH FENCE 06 FALLING 07 HIT BY BAT 08 HORSEPLAY 09 PITCHED BALL 10 RUNNING 11 SHARP OBJECT 12 SLIDING 13 TAGGING 14 THROWING 15 THROWN BALL 16 OTHER 17 UNKNOWN
Does your league use breakaway bases on: ALL SOME NONE of your fields? Does your league use batting helmets with attached face guards? YES NO If YES, are they Mandatory or Optional At what levels are they used? I hereby certify that the above named claimant was injured while covered by the Little League Baseball Accident Insurance Policy at the time of the reported accident. I also certify that the information contained in the Claimant’s Notification is true and correct as stated, to the best of my knowledge. Date
League Official Signature
Page 61 of 88 Little League®Béisbol y Softbol
INSTRUCCIONES DEL FORMULARIO DE RECLAMO Para los reclamos que sucedieron después de enero 1 del 2005 ADVERTENCIA – Es importante que los padres/tutores y jugadores tomen nota que: El equipo de protección no puede prevenir todas las lesiones que un jugador puede recibir mientras participa en el béisbol/softbol. Para agilitar el reporte de las lesiones del personal de la liga, hemos preparado directrices para utilizarlas como una lista al llenar los informes. Esto ahorrará tiempo – y acelerará su pago de reclamos. La Póliza Máster de Accidentes de NUFI adquirida a través de las Pequeñas Ligas contiene una “Provisión de Exceso de Cobertura” por lo cual todo el seguro personal y/o corporativo debe utilizarse primero. Para ayudar a explicar la cobertura del seguro a los padres/tutores remítase a Lo que los Padres Deberían Saber en Internet que debería reproducirse en el membrete de su liga y distribuirse a los padres/tutores de todos los participantes al momento de la inscripción. Si ocurren lesiones, inicialmente es necesario determinar si los padres/tutores del demandante o el demandante tienen otro seguro como corporativo, de empleado, Cruz Azul y Escudo Azul, etc., que pague beneficios. (Esta información debería obtenerse en el momento de la inscripción previo a las pruebas.) Si tal cobertura es proporcionada, la demanda debe ser archivada primero con la compañía principal bajo la cual el padre/tutor o demandante está asegurado. Cuando se llena una demanda, todos los gastos médicos deberían detallarse y enviarse a la Sede. Si ningún otro seguro está vigente, una carta del padre/tutor o demandante del empleado debería acompañar el formulario de reclamo explicando la falta de seguro corporativo o personal. La Póliza de Accidentes de la NUFI se adquiere por ligas, no padres, y proporciona una cobertura comprensiva a un costo razonable. La cobertura de accidentes está asegurada por la Compañía de Seguros de Incendios de la Unión Nacional de Pittsburg, Pa., con su sitio principal de negocios en Nueva Cork, NY. Esta es una descripción breve de la cobertura disponible bajo la póliza. La póliza contendrá limitaciones, exclusiones y provisiones de terminación. Con la cooperación de su liga, las tasas de seguro han incrementado solamente tres veces desde 1965. Esta estabilidad de la tasa no sería posible sin su ayuda en el énfasis de los programas de seguridad a nivel local. El manual de ASAP, Kit del Programa del Oficial de Seguridad de la Liga, se recomienda para el uso por su Oficial de Seguridad. En el 2000 el Estado de Virginia fue el primer estado en tener sus tasas del seguro de accidentes reducidas por su alta participación en la ASAP y la reducción de lesiones. En el 2002, siete estados más también han tenido sus tasas del seguro de accidentes reducidas. Ellos son Alaska, California, Delaware, Idaho, Montana, Washington, Wisconsin.
TRATAMIENTO DE LESIONES DENTALES Tratamiento Dental Diferido para demandas o lesiones que ocurrieron en el 2002 y después: Si el asegurado incurre en lesión dientes naturales sólidos y se requiere tratamiento necesario, ese tratamiento dental para esa lesión debe ser pospuesto para una fecha mayor de 52 semanas después de la fecha de la lesión vencida, pero no limitada a los cambios fisiológicos que ocurren a un asegurado que es un niño que está creciendo, pagaremos el menor del beneficio máximo de $1.500,00 o el gasto razonable incurrido por el tratamiento dental diferido. Los gastos razonables incurridos por tratamiento dental diferido son
Page 62 of 88 solamente cubiertos si son incurridos durante o antes del cumpleaños número 23 del asegurado. Los gastos razonables incurridos por tratamiento de conducto diferido son cubiertos solamente si son incurridos dentro de las 104 semanas después de la fecha de la lesión.
Page 63 of 88 LISTA PARA PREPARAR EL FORMULARIO DE RECLAMO 1. Imprima o escriba a máquina toda la información. 2. Llene todas las partes del reclamo antes de enviarlo a nuestra oficina. 3. Asegúrese de incluir el nombre de la liga y el número de identificación de la liga.
PARTE I – DEMANDANTE O PADRE(S)/TUTOR(ES), SI EL DEMANDANTE ES MENOR 1. El demandante adulto o padre(s)/tutor(es) deben firmar esta sección, si el demandante es un menor. 2. Ponga el nombre y dirección de la persona lesionada, junto con el nombre y la dirección del padre(s)/tutor(es), si el demandante es un menor. 3. Llene todas las secciones, incluyendo las marcas de comprobación en los casilleros apropiados para todas las categorías. No deje ninguna sección en blanco. Esto causará una demora en el proceso de su demanda y una copia del formulario de la demanda será devuelto a usted para su conclusión. 4. Es obligatorio enviar la información de otro seguro. Sin esa información habrá una demora en el proceso de su reclamo. Si no tiene seguro, una verificación escrita de cada padre/cónyuge del empleado debe presentarse. 5. Asegúrese que todos los papeles necesarios estén adjuntados en el formulario de demanda. (Vea la instrucción 3.) Solamente las facturas detalladas se aceptan. 6. En demandas dentales, es necesario presentar los cargos a la compañía de seguro dental y médico del demandante, o padre(s)/tutor(es) si el demandante es un menor. “Tratamiento de accidentes relacionados para todo, dientes naturales sólidos como resultados directos e independientes de un accidente” debe indicarse en el formulario y facturas. Por favor envíe una copia de la respuesta de la compañía de seguros a la Sede de las Pequeñas Ligas. Incluya en el formulario el nombre del demandante, número de identificación de la liga, y año de la lesión.
PARTE II – DECLARACIÓN DE LA LIGA 1. Esta sección debe ser llenada, firmada y fechada por el oficial de la liga. 2. Llene todas las secciones, incluyendo una marca de comprobación en los casilleros apropiados para todas las categorías. No deje ninguna sección en blanco. Esto causará una demora en el proceso de su reclamo y una copia del formulario de la demanda será devuelto a usted para su conclusión.
IMPORTANTE: La notificación de un reclamo debería archivarse con las Pequeñas Ligas Internacional dentro de los 20 días del incidente para la temporada actual.
05-008-02 Mis documentos seguros instrucciones del formulario de demanda-03
Little League Baseball and Softball ®
M E D I C A L
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R E L E A S E
NOTE: To be carried by any Regular Season or Tournament Team Manager together with team roster or International Tournament affidavit. Player: _____________________________________
Date of Birth: ____________ Gender (M/F):_________________
Parent (s)/Guardian Name:_____________________________________ Relationship:____________________________ Parent (s)/Guardian Name:_____________________________________ Relationship:____________________________ Player’s Address:____________________________________ City:_______________ State/Country:________ Zip:______ Home Phone:_____________________ Work Phone:______________________ Mobile Phone:_____________________ PARENT OR LEGAL GUARDIAN AUTHORIZATION:
Email: ____________________________
In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel. (i.e. EMT, First Responder, E.R. Physician) Family Physician: ____________________________________________ Phone: _________________________________ Address: __________________________________________ City:________________ State/Country:_________________ Hospital Preference: __________________________________________________________________________________ Parent Insurance Co:_________________________ Policy No.:__________________Group ID#:_____________________ League Insurance Co:_________________________ Policy No.:__________________League/Group ID#:______________ If parent(s)/legal guardian cannot be reached in case of emergency, contact: ___________________________________________________________________________________________________ Name Phone Relationship to Player ___________________________________________________________________________________________________ Name Phone Relationship to Player Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder)
Medical Diagnosis
Medication
Dosage
Frequency of Dosage
Date of last Tetanus Toxoid Booster: ______________________________________________________________________ The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.
Mr./Mrs./Ms. ________________________________________________________________________________________ Authorized Parent/Guardian Signature Date: FOR LEAGUE USE ONLY: League Name:_______________________________________________ League ID:________________________________ Division:_________________________________Team:______________________________ Date:____________________ WARNING: PROTECTIVE EQUIPMENT CANNOT PREVENT ALL INJURIES A PLAYER MIGHT RECEIVE WHILE PARTICIPATING IN BASEBALL/SOFTBALL. Little League does not limit participation in its activities on the basis of disability, race, color, creed, national origin, gender, sexual preference or religious preference.
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Little League Béisbol y Softbol ®
Revelación Médica NOTA: A llevarse a cabo por cualquier Temporada Regular o Dirigente del Equipo del Torneo junto con el róster del equipo o declaración jurada de elegibilidad.
Jugador:
Fecha de Nacimiento:
Nombre de la Liga:
Número de Identidad:
Autorización del Padre o Tutor: En caso de emergencia, si no se puede llegar al médico familiar, Yo, por la presente autorizo que mi hijo sea tratado por el Personal de Emergencia Certificado. (es decir, TME, Primeros Auxilios, Médico de Emergencia) Médico Familiar:
Teléfono:
Dirección: Hospital de Preferencia: En caso de emergencia contactar a: ___________________________________________________________________ Nombre
Teléfono
Relación con el Jugador
___________________________________________________________________ Nombre
Teléfono
Relación con el Jugador
Por favor liste cualquier alergia/problema médico, incluyendo aquellos que requieran medicamentos permanentes. (es decir, Diabético, Asma, Trastorno de Convulsión) Diagnóstico Médico
Medicamentos
Dosificación
Frecuencia de Dosificación
El propósito de la información listada arriba es asegurar que el personal médico tenga detalles de cualquier problema médico el cual pueda interferir con o alterar el tratamiento. Fecha de la última dosis de refuerzo de toxina del tétano: ________________________________ Sr./Sra./Srta. ___________________________________________________ Firma del Padre/Tutor Autorizado
Page 66 of 88 PRECAUCIÓN El equipo de protección no puede prevenir todas las lesiones que un jugador podría recibir durante la participación en Béisbol/Softbol. Las Pequeñas Ligas no limita la participación en sus actividades sobre una base de discapacidad, raza, color, credo, origen nacional, género, preferencia sexual o religiosa.
Mis documentos/provisiones de la liga/2005/formulario de revelación médica
It is suggested this memo should be reproduced on your league’s letterhead over the signature Page 67 ofof88 your president or safety officer and distributed to the parents of all participants at registration time. WARNING: Protective equipment cannot prevent all injuries a player might receive while participating in Baseball / Softball. WHAT PARENTS SHOULD KNOW ABOUT LITTLE LEAGUE® INSURANCE The Little League Insurance Program is designed to afford protection to all participants at the most economical cost to the local league. The Little League Player Accident Policy is an excess coverage, accident only plan, to be used as a supplement to other insurance carried under a family policy or insurance provided by an employer. If there is no primary coverage, Little League insurance will provide benefits for eligible charges, up to Usual and Customary allowances for your area. A $50 deductible applies for all claims, up to the maximum stated benefits. This plan makes it possible to offer exceptional, affordable protection with assurance to parents that adequate coverage is in force for all chartered and insured Little League approved programs and events. If your child sustains a covered injury while taking part in a scheduled Little League Baseball or Softball game or practice, here is how the insurance works: 1. The Little League Baseball and Softball accident notification form must be completed by parents (if the claimant is under 19 years of age) and a league official and forwarded directly to Little League Headquarters within 20 days after the accident. A photocopy of the form should be made and kept by the parent/claimant. Initial medical/dental treatment must be rendered within 30 days of the Little League accident. 2. Itemized bills, including description of service, date of service, procedure and diagnosis codes for medical services/ supplies and/or other documentation related to a claim for benefits are to be provided within 90 days after the accident. In no event shall such proof be furnished later than 12 months from the date the initial medical expense was incurred. 3. When other insurance is present, parents or claimant must forward copies of the Explanation of Benefits or Notice/ Letter of Denial for each charge directly to Little League International, even if the charges do not exceed the deductible of the primary insurance program. 4. Policy provides benefits for eligible medical expenses incurred within 52 weeks of the accident, subject to Excess Coverage and Exclusion provisions of the plan. 5. Limited deferred medical/dental benefits may be available for necessary treatment after the 52-week time limit when: (a) Deferred medical benefits apply when necessary treatment requiring the removal of a pin /plate, applied to transfix a bone in the year of injury, or scar tissue removal, after the 52-week time limit is required. The Company will pay the Reasonable Expense incurred, subject to the Policy’s maximum limit of $100,000 for any one injury to any one Insured. However, in no event will any benefit be paid under this provision for any expenses incurred more than 24 months from the date the injury was sustained. (b) If the Insured incurs Injury, to sound, natural teeth and Necessary Treatment requires treatment for that Injury be postponed to a date more than 52 weeks after the injury due to, but not limited to, the physiological changes of a growing child, the Company will pay the lesser of: 1. A maximum of $1,500 or 2. Reasonable Expenses incurred for the deferred dental treatment. Reasonable Expenses incurred for deferred dental treatment are only covered if they are incurred on or before the Insured’s 23rd birthday. Reasonable Expenses incurred for deferred root canal therapy are only covered if they are incurred within 104 weeks after the date the Injury occurs. No payment will be made for deferred treatment unless the Physician submits written certification, within 52 weeks after the accident, that the treatment must be postponed for the above stated reasons. Benefits are payable subject to the Excess Coverage and the Exclusions provisions of the Policy. We hope this brief summary has been helpful in providing a better understanding of the operation of the Little League insurance program.
Page 68 of 88 Se sugiere que este memo se reproduzca en el papel membretado de su liga con la firma de su presidente u oficial de seguridad y se distribuya a los padres de todos los participantes en el momento del registro. PRECAUCIÓN: El equipo de protección no puede prevenir todas las lesiones que un jugador podría recibir al practicar Béisbol /Softbol. LO QUE LOS PADRES DEBEN SABER ACERCA DEL SEGURO DE LAS PEQUEÑAS LIGAS El Programa de Seguro de las Pequeñas Ligas está diseñado a producir protección a todos los participantes al costo más económico a la liga local. La Política de Accidentes del Jugador de las Pequeñas Ligas es un plan de cobertura extra solo para accidentes, para usar como suplemento para otros seguros llevados bajo las políticas de una familia o seguro proporcionado por el empleador del padre. Si no existe cobertura primaria, el seguro de las Pequeñas Ligas le proporcionará beneficios por cambios elegibles, hasta permisos Usuales y Acostumbrados para su área, después de un deducible de $50.00 por reclamo, hasta el máximo de beneficios indicado. Este plan hace posible ofrecer protección excepcional y alcanzable asegurando a los padres quienes su cobertura adecuada están en función para todos los eventos y programas aprobados por las Pequeñas Ligas asegurados. Si su hijo tiene una lesión cubierta mientras forma parte de un juego o práctica programada de las Pequeñas Ligas de Béisbol o Softbol, así es como funciona el seguro: 1. Se debe completar el formulario de notificación de accidente de las Pequeñas Ligas de Béisbol por los padres (si el demandante es menor de 19 años) y un oficial de la liga y dirigido directamente a la Sede de las Pequeñas Ligas dentro de 20 días después del accidente. Se debe sacar una copia del formulario y lo debe mantener el padre/demandante. Se debe iniciar el tratamiento médico/dental dentro de 30 días del accidente de la Pequeña Liga. 2. Facturas detalladas, incluyendo la descripción del servicio, fecha del servicio, procedimiento y códigos de diagnósticos para servicios/provisiones médicas y/u otra documentación relacionada a un reclamo por beneficios deben proporcionarse dentro de 90 días después del accidente. De ninguna manera tal prueba debe proporcionarse después de 12 meses a partir de la fecha inicial en que incurrió el gasto médico. 3. Cuando está presente otro seguro, los padres o el demandante debe dirigir copias de la Explicación de Beneficios o Notificación/Carta de Negación de cada cargo directamente a la Sede de las Pequeñas Ligas, aún si los cargos no exceden el deducible del programa de seguro principal. 4. La política proporciona beneficios para gastos médicos elegibles incurridos dentro de 52 semanas del accidente, sujetos a provisiones de Cobertura Excesiva y Exclusión del plan. 5. Beneficios médicos/dentales limitados diferidos pueden estar disponibles para tratamiento necesario después del límite de 52 semanas cuando: (a) Los beneficios médicos diferidos aplican cuando es necesario un tratamiento requerido para quitar un clavo/placa, aplicada para reconstruir un hueso al año de lesión, o para quitar una cicatriz, se requiere después del límite de 52 semanas. La Compañía pagará el Gasto Razonable incurrido, sujeto al límite máximo de $100,000 de la Política para cualquier lesión a cualquier asegurado. Sin
Page 69 of 88 embargo, en ningún caso se pagará a ningún beneficiario bajo esta provisión por cualquier gasto incurrido más de 24 meses desde la fecha en que ocurrió la lesión. (b) Si el asegurado incurre una lesión, a los dientes naturales sanos y requiere un Tratamiento Necesario para esa lesión y se pospone a una fecha mayor a 52 semanas después de la lesión debido a, pero no limitado a, los cambios fisiológicos de un niño en crecimiento, la Compañía pagará al menos: 1. Un máximo de $1.500 o 2. Gastos razonables incurridos por el tratamiento dental diferido. Gastos Razonables incurridos por el tratamiento dental diferido solo se cubren si se incurren durante o antes el 23avo cumpleaños del asegurado. Gastos Razonables incurridos por terapia de tratamiento de endodoncia diferido solo se cubren si se incurren dentro de 104 semanas después que ocurrió la lesión. No se hará ningún pago por tratamiento diferido a menos que el Médico entregue un certificado escrito, dentro de 52 semanas después del accidente, que el tratamiento se debe posponer por las razones antes declaradas. Los beneficios se pueden pagar sujetos a la Cobertura Excesiva y las provisiones de Exclusiones de la Política. Esperamos que este resumen escrito haya sido de ayuda para el mejor entendimiento de un importante aspecto de la operación del programa de seguro aprobado de las Pequeñas Ligas.
Page 70 of 88 12.0
FIRST-AID KITS
•
First-aid kits and safety manuals are provide to each team
•
Additional first-aid kits are available in the storage bins at all scheduled practice fields.
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SAN MATEO NATIONAL LITTLE LEAGUE LOCAL RULES Safety rules for SMNLL are shown on page 4 of the following (SMNLL 2017 Local Rules)
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16.0
NATIONAL BACKGROUND SCREENING
In conjunction with First Advantage, SMNLL conducts national background checks on all managers/coaches, board members, and volunteers who have repetitive interactions with player’s.
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Little League Volunteer Application -2017 ®
Do not use forms from past years. Use extra paper to complete if additional space is required. A COPY OF VALID GOVERNMENT ISSUED PHOTO IDENTIFICATION MUST BE ATTACHED TO COMPLETE THIS APPLICATION. Name __________________________________ Date ___________________ Address ________________________________________________________ City ____________________________ State _________Zip _____________ Social Security # (mandatory with First Advantage or upon request) _______________ Cell Phone Business Phone Home Phone: E-mail Address: Date of Birth ____________________________________________________ Occupation _____________________________________________________ Employer _______________________________________________________ Address ________________________________________________________ Special professional training, skills, hobbies: ___________________________ Community affiliations (Clubs, Service Organizations, etc.): Previous volunteer experience (including baseball/softball and year):
Please list three references, at least one of which has knowledge of your participation as a volunteer in a youth program: Name/Phone
AS A CONDITION OF VOLUNTEERING, I give permission for the Little League organization to conduct background check(s) on me now and as long as I continue to be active with the organization, which may include a review of sex offender registries (some of which contain name only searches which may result in a report being generated that may or may not be me), child abuse and criminal history records. I understand that, if appointed, my position is conditional upon the league receiving no inappropriate information on my background. I hereby release and agree to hold harmless from liability the local Little League, Little League Baseball, Incorporated, the officers, employees and volunteers thereof, or any other person or organization that may provide such information. I also understand that, regardless of previous appointments, Little League is not obligated to appoint me to a volunteer position. If appointed, I understand that, prior to the expiration of my term, I am subject to suspension by the President and removal by the Board of Directors for violation of Little League policies or principles. Applicant Signature _______________________________________ Date _________
Do you have children in the program? Yes No If yes, list full name and what level? _____________________________________________________ Special Certification (CPR, Medical, etc.): ______________________________ Do you have a valid driver’s license: Yes No Driver’s License#: ________________________________State ___________ Have you ever been convicted of or plead guilty to any crime(s) involving or against a minor?: Yes No If yes, describe each in full:_________________________________________ Are there any criminal charges pending against you regarding any crime(s) involving or against a minor? Yes No If yes, describe each in full:______________ Have you ever been refused participation in any other youth programs? Yes No If yes, explain: ___________________________________________________ In which of the following would you like to participate? (Check one or more.) League Official Coach Umpire Field Maintenance Manager Scorekeeper Concession Stand Other
If Minor/Parent Signature___________________________________Date __________ Applicant Name(please print or type) _______________________________________ NOTE: The local Little League and Little League Baseball, Incorporated will not discriminate against any person on the basis of race, creed, color, national origin, marital status, gender, sexual orientation or disability.
LOCAL LEAGUE USE ONLY: Background check completed by league officer ________________________________ on ____________________________________________________________________ System)s) used for background check (minimum of one must be checked): Sex Offender Registry
Criminal History Records
*First Advantage
*Please be advised that if you use First Advantage and there is a name match in the few states where only name match searches can be performed you should notify volunteers that they will receive a letter directly from LexisNexis in compliance with the Fair Credit Reporting Act containing information regarding all the criminal records associated with the name, which may not necessarily be the league volunteer.
Only attach to this application copies of background check reports that reveal convictions of this application. 1-02-11-VOLUNTEER APPLICATION 3/28/11
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Little League International User Guide for Vendors November 2013 FADV0017
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CONFIDENTIAL & PROPRIETARY The recipient of this material (hereinafter "the Material") acknowledges that it contains confidential and proprietary data the disclosure to, or use of which by, third parties will be damaging to First Advantage. Therefore, recipient agrees to hold the Material in strictest confidence, not to make use of it other than for the purpose for which it is being provided, to release it only to employees requiring such information, and not to release or disclose it to any other party. Upon request, recipient will return the Material together with all copies and modifications, if any. All names in the text, or on the sample reports and screens shown in this document, are of fictitious persons and entities. Any similarity to the name of any real person, address, school, business or other entity is purely coincidental. The First Advantage logo is a registered trademark of First Advantage, used under license. Other products and services may be trademarks or registered trademarks of their respective companies. Copyright © 2013, First Advantage. All rights reserved.
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Little League International User Guide FADV0017
November 2013
Table of Contents Introduction .......................................................................................................................... 4 Register a New League .......................................................................................................... 4 Log In ..................................................................................................................................... 6 Add Person ............................................................................................................................ 7 Submit an Order .................................................................................................................... 8 Search for a Person ................................................................................................................ 8 Terminate or Deactivate a Person.......................................................................................... 9 Basic Administration Functions ............................................................................................ 10 Add a new user.................................................................................................................................................................. 10 Change user notifications ................................................................................................................................................. 11 Change password .............................................................................................................................................................. 12
Copyright © 2013 First Advantage. All rights reserved.
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Little League International User Guide FADV0017
November 2013
Introduction This guide provides you with key information for using the Little League background check website for the most‐ frequently‐used features: ordering background reports and managing users. If you need assistance, please contact the First Advantage customer support team by telephone or email at 1‐866‐399‐ 6647 or
[email protected].
Register a New League To access the website, enter the URL provided to you by First Advantage in your browser’s address bar. The URL is case‐ sensitive; enter upper and lower case letters exactly as they appear on your notification. For future reference, bookmark or add the URL to the favorites in your browser. Before you begin using the system, you must register your vendor account. 1. Select the link below the login page fields.
2. Enter and validate your League ID.
a. If the League ID is already registered to another owner, you will be prompted to register as the league owner. Select the click here hyperlink to access the Change Request Form.
b. Complete the Change Request Form, then select Submit Request. Copyright © 2013 First Advantage. All rights reserved.
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November 2013
3. Create a user ID and password and complete the other sections of the registration form. Note: Required fields are indicated by an asterisk (*).
In the Primary Contact Information section, enter the information for the person at your firm who will be the primary contact for screening activities. Note that a valid email address is required for the primary contact. 4. Read and electronically sign and date the Background Screening Services Agreement. Then, select AGREE AND SUBMIT REGISTRATION.
5. Review the registration information to verify its accuracy. If you need to correct anything, select GO BACK. If all information is correct, select CONFIRM.
Copyright © 2013 First Advantage. All rights reserved.
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Little League International User Guide FADV0017
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6. Once you have confirmed your registration information, the system shows a message that you have registered successfully, which includes a transaction number for reference. The system also sends you an email confirmation. Your account will be activated within 1 to 2 business days.
Log In To access the background check system after initial registration, use the same URL as you did to register your vendor account. 1. Enter the user ID and password you created during registration and click Log In. 2. Upon first log in, you must certify that you have complied with requirements for ordering screening reports by accepting the legal agreement. To certify that you comply with the legal agreement, select ACCEPT LEGAL AGREEMENT.
3. Each time you log in, you must certify that you have complied with requirements for ordering screening reports by accepting the Fair Credit Reporting Act (FCRA) agreement. To certify that you comply with the FCRA, select ACCEPT FCRA AGREEMENT.
4. The Home page displays. From this page, you may view the number of free searches remaining for the current fiscal year and the Important Notice on Background Checks for Little Leagues. From the Home page, you may perform the following tasks.
Add a person/employee.
Submit an order.
Search for a person/employee and view compliance.
Edit employee status.
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Add Person To order a background screening on an individual, you must add that person to the system. 1. Select People > Add New Person.
2. Enter information for the new person on the Person Information screen Note: Required fields are indicated by an asterisk (*).
3. Make sure all information is correct and select SAVE. The person is immediately added to the roster.
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Submit an Order Note: Be sure to obtain a signed consent form before submitting an order. 1. On the Person Status Detail page, select BEGIN ORDER PROCESS.
The system then displays the Background Check Order Detail page. 2. Select the desired screening package. Review the package details. If you do not already have a signed consent form, select on the hyperlink, print the form, and obtain the signature. Select the consent confirmation checkbox, and select Next.
3. Select SUBMIT ORDER.
Search for a Person People Search enables you to view compliance status of the background screening and to perform other tasks related to individuals on your roster. 1. Select People > Search People.
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2. Search by entering one or more of the desired search criteria – typically an individual’s SSN or name. You may enter partial search data. Select SEARCH. If you don’t enter any search criteria, the system displays a complete roster of all individuals added under your account.
3. View the search results at the bottom of the page to determine whether or not the individual’s background report has a status of Compliant.
You can sort the results by selecting the arrows next to each heading. Note that SSNs are masked to comply with privacy requirements. If the person is not in the list, you may need to add the person to the system and submit an order. 4. To export the search results list to MS Excel, select on the Excel icon at the bottom of the page.
Terminate or Deactivate a Person 1. Follow the instructions for Search for a Person above to locate the individual to deactivate or terminate. 2. Select on the person’s name from in the results list to view their Person Status Detail.
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3. Select EDIT INFORMATION.
4. Select the arrow next to Active Status to display a list of possible statuses.
5. Select the new status for this person. 6. Select SAVE to complete the status change. a. Select CANCEL to cancel the status change and return to the Person Status Detail page.
Basic Administration Functions Add a new user 1. Select Administration > Add New User.
Password requirements and Role permissions are described on this page. 2. Enter the new user’s:
User ID;
Password;
First Name;
Last Name; and
Role (Admin, View, Update or Summary).
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3. Select the new user’s User Notifications and select SAVE. The new user will be able to log into the system immediately with the User ID and Password assigned.
Change user notifications 1. Select Administration > Profile.
You must enter your current password to edit all profile information.
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2. Under the User Notifications section, you can see what notifications you currently receive. You can change these settings at any time. Make your new selections and select SAVE.
Change password 1. Select Administration > Profile.
You must enter your current password to edit all profile information.
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2. Select CHANGE YOUR PASSWORD.
3. Enter your new password in both fields and select SAVE.
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