2014 Western Little League Safety Manual...Mushball: Jeff Barrett 616.822.6374 [email protected] Softball Jr/Sr: Bob Wynsma 616.893.2804 [email protected] Softball Min/Maj: Brad VanManen

2014 Western Little League Safety Manual

www.GRWESTERNLL.COM

ASAP

2014 WESTERN LITTLE LEAGUE SAFETY MANUAL – TABLE OF CONTENTS League & Emergency Contacts ............................................................................ 2 Safety Program Details ......................................................................................... 3 Severe Weather Policy .......................................................................................... 4 Concession Stand Information .............................................................................. 5 Local Rules ........................................................................................................... 6 Appendices A. Child First Aid/CPR/AED Reference (American Red Cross) ....................... 9 B. Adult First Aid/CPR/AED Reference (American Red Cross) ..................... 21 C. Volunteer Applications .............................................................................. 33 D. Accident Claim Form Instructions ............................................................. 35 E. Accident Claim Form ................................................................................. 37 F. Injury Tracking Form .................................................................................. 39

www.GRWESTERNLL.com

www.GRWESTERNLL.com 2

2014 WESTERN LITTLE LEAGUE SAFETY MANUAL – LEAGUE & EMERGENCY CONTACTS

Western Little League P.O. Box 140731

Grand Rapids, MI 49514

2014 League Officers President: Rob Stellini 616.366.8654 [email protected] 2121 Cider Mill Trail, Walker MI 49534 Safety Officer: Alan Plum 616.648.4972 [email protected] 703 Larkspur Ave NW, Grand Rapids MI 49504 Player Agent: Jim Buchanan 616.821.4094 [email protected] Treasurer Joe Tuttle 616.299.3156 [email protected] Secretary: Sharon Kailing 616.460.8391 [email protected] Information Officer: Adam Zavislak 616.485.8224 [email protected] Field Manager: Justin Miller 616.901.8479 [email protected] Equipment Mgrs: John Onderko 616.735.2319 [email protected] Joe Ricord 616.648.3294 [email protected] Concessions Mgr: Sabra Szczepaniak 616.589.4948 [email protected] Sponsors/Uniforms: Mike Velzen 616.901.4608 [email protected] Umpire in Chief: Jeff Tuttle 616.813.3127 [email protected] Coaching Coordinator: Troy Clinger 616.291.6981 [email protected] 2014 League Vice-Presidents Boys JR/SR: Roger Sweedyk 616.295.8505 [email protected] Boys Majors: Alan Plum 616.648.4972 [email protected] Boys Minors Bill Krall 616.890.8318 [email protected] Coach Pitch Justin Miller 616.901.8479 [email protected] Teeball: Jason Carlson 616.719.9329 [email protected] Mushball: Jeff Barrett 616.822.6374 [email protected] Softball Jr/Sr: Bob Wynsma 616.893.2804 [email protected] Softball Min/Maj: Brad VanManen 616.915.3678 [email protected] Joe Pietrusza 616.238.1733 [email protected]

EMERGENCY NUMBERS Fire and Medical DIAL 911 Grand Rapids Police (non-emergency) 616-456-3400 AMBULANCE SERVICE Life EMS (616) 458-LIFE (5433) 888-LifeEMS (888-543-3367) American Medical Response (AMR) Main: (616) 459-8228 Dispatch: (616) 459-8197

2014 FIELD LOCATIONS

SHAWMUT HILLS ELEMENTARY SCHOOL 2550 Burritt NW, Grand Rapids MI 49504

Mushball, T-Ball, Coach Pitch, Minors & Majors

KENOWA HILLS HIGH SCHOOL 3825 Herndershot NW, Grand Rapids MI 49544

Girl’s Softball (All Divisions) Juniors & Seniors (Baseball)


2014 WESTERN LITTLE LEAGUE SAFETY MANUAL – SAFETY PROGRAM DETAILS 1) This plan and the Annual Little League Facility Survey will be submitted to Little League International as prepared by 2014 Western Little League (WLL) Safety Officer Alan Plum, who will be registered with Little League International. 2) Western Little League will distribute a copy of this Safety Manual to all Coaches, League Volunteers and the District Administrator. It will also be made available via the League’s official website: www.GRWESTERNLL.COM 3) A copy of the 2014 WLL Safety Manual will also be available in the WLL Concession Stand for anyone who wishes to review it. Subsequently, a meeting will be held prior to the start of the season with concessions workers to review proper food handling procedures and safety measures. 4) All WLL Coaches/Volunteers are required to submit the Official 2014 Little League Volunteer Application (see appendix) along with a valid government issued photo identification. All Coaches and Registered Volunteers will be subject to background checks. 5) Prior to the start of the season, WLL will attempt to make first aid and/or CPR training available to all Coaches. If possible, this will include AED (automatic external defibrillator) training. The AED is located at the WLL Concession Stand at Shawmut Hills Elementary. 6) Coaches at all levels of WLL will complete the online “Heads Up” Concussion training for youth sports available at: http://www.cdc.gov/concussion/headsup/training/

7) Whenever possible, instructional clinics will be made available to all WLL Coaches. In addition, all umpires must attend the umpire’s clinic as directed by the Umpire in Chief 8) All WLL Coaches will receive an equipment bag for team use. The contents of the bag will haven been inspected by WLL Equipment Managers, prior to distribution. Each equipment bag will include a first aid kit. Coaches are to have the first aid kit on hand at all practices and games. All WLL issued equipment is to be returned at the end of the season. 9) All WLL Coaches shall inspect their equipment prior to all practices and games to ensure that damaged items are replaced or taken out of use and destroyed when necessary. Any equipment issues should be reported to the WLL Equipment Managers. 10) All WLL Coaches and Umpires are required to walk/inspect their fields prior to practices and games. Any field or facility issues should be reported immediately to the WLL Safety Officer 11) Any accidents should be reported to Safety Officer or League President immediately. WLL will use the incident tracking form provided by Little League International (see appendix) to achieve prompt accident reporting. Completed forms are to be provided to the WLL Safety Officer within 48 hours of the incident. This manual includes all necessary insurance forms. 12) Western Little League will abide by Official Little League Rules. A copy of WLL’s Local Rules are included in this manual. Coaches are expected to enforce all rules and to emphasize safety first at all games and practices.


2014 WESTERN LITTLE LEAGUE SAFETY MANUAL – SEVERE WEATHER POLICY

Western Little League will adhere to the Severe Weather Policy used by District 9 of Michigan.

• If a Severe Thunderstorm Warning and/or Tornado Warning/Watch are in effect ½ hour prior to the arrival of teams at the fields for games, all games WILL BE cancelled.

• Games may proceed if a Thunderstorm or Tornado Watch are issued during play.

• In the event of thunder and/or lightning, ALL players must be immediately removed from the playing field by their respective coaches. They may be kept in the dugouts as long as one coach is present. Players may be released to their parents/guardians.

• On fields where covered dugouts are not present, players will be reunited with their parents/guardians to seek shelter in personal vehicles.

• Play will be halted until the severe weather had cleared the area.

• Play will not resume until 20 minutes have elapsed without an occurrence of thunder or lightning.

• Coaches who fail to follow these procedures will be subject to disciplinary action.

• Any cancellations due to severe weather will be posted to the Western Little League website (www.GRWESTERNLL.com). Additionally, WLL will attempt to issue notifications of any cancellations via the league’s information systems.

• All coaches will establish procedures to contact their players in the event of cancellations.

• Cancelled games will be rescheduled at the discretion of the League VP, the respective coaches, and the WLL Board of Directors.

In the event of rain, please arrive at the field for the normal scheduled game. We can make the determination for cancellation at or near game time.


2014 WESTERN LITTLE LEAGUE SAFETY MANUAL – CONCESSION STAND INFORMATION Western Little League Concessions Manager: Sabra Szczepaniak Phone: 616.589.4948 Email: [email protected]

• The Concessions Manager will receive a copy of the 2014 Western Little League Safety Manual. A meeting will be held in late March with all concessions workers to review all safety issues and to discuss proper food handling practices.

• No person under the age of 13 will be allowed to handle money, or serve hot items such

as popcorn, coffee, or grilled items.

• Workers will wash their hands prior to handling any food products.

• All volunteers working in the concession stand will be required to sign in at the beginning of their shift and sign out upon their departure.

• Each scheduled group will designate one person to oversee the cash register. This

designation is to be communicated with the concession manager.

• Concession Volunteers are to remain until the end of ALL weeknight games. Saturday shifts will cover a two-hour period. Volunteers are to arrive 15 minutes prior to their shift.

• Only authorized personnel are to be in the food service area while the concession stand

is open. Coaches, umpires and players are NOT to be in the food service area.

• Concession stand volunteers may NOT consume any item in the concession stand unless it has been purchased.

• All Team Beverage purchases must be paid before players are allowed to select an item.

All Team purchases should be recorded and crossed out upon the distribution of the items.


2014 WESTERN LITTLE LEAGUE SAFETY MANUAL – LOCAL RULES Note: Nothing in these local rules will interfere with the official rules and regulations of little league baseball incorporated or the Constitution of Western little league.

Formation of Teams

The drafting method for all divisions will be determined by the WLL Board of Directors.

Division Alignment for the 2014 Season will be consist of the following:

Boys and Girls 4,5 Years old Mush ball

Boy and Girls 6,7 Years old Tee-Ball

Boys and Girls 7,8 Years old Coach Pitch

Boys 9 & 10 years old Boys Minors

Boys 11 & 12 Years old Boys Majors

Boys 13 &14 Years old Boys Juniors

Boys 15 &16 Years old Boys Seniors

Girls 8,9 & 10 Years old Girls Minors

Girls 11&12 Years old Girls Majors

Girls 13&14 Years old Girls Juniors

Girls 15 & 16 Years old Girls Seniors

Boys Age as of 4/30/2014 (League Age) Girls Age as of 12/31/2013 (League Age)

Age restrictions may be changed to properly adjust team sizes and numbers. (e.g 7 year old may play coach pitch if they have played a season or more of Tee-ball and the teams in Coach Pitch need additional players). Any player movement must be approved by the WLL Board of Directors. All decisions will be final.

The player agent must approve all call-ups from the Minor League to the Major League. No Minor league player called up to the Major League may play more innings than a regular Major League player unless required by injury or illness or to fill out the team. The Player Agent must approve all 8 year olds that are to play Minor League. No player may step down without the approval of the WLL Board of Directors and parental consent. An evaluation of player’s ability must be performed in order for this provision to take place.


Selection of Coaches

Managers must apply and will be selected based on the rules and regulations of Little League International as described in the WLL Constitution.

Any Board member, coach, player or volunteer not sincerely interested in promoting the objectives of WLL may be removed by the WLL Board of Directors as described in the Little League rulebook.

The President is to appoint coaches at his/her discretion. The Board of Directors must approve these appointments. A President and/or Board of Directors should not give a reason to a person if he/she is not re-appointed or re-approved. No coach has tenure, regardless of years of service. Any Board member may offer up the name of a potential coach should the President fail to do so.

All Coaches, assistant coaches will complete by the Volunteer Application and consent to a Background check.

The Board of Directors shall have a special meeting to approve the appointment of all coaches. The President is to schedule this meeting on or before March 1st for Mush ball to Boys/Girls Major divisions. Boys/Girls Junior, Senior Divisions should be appointed by May 1st of each season.

All-Star Selection

The method for selecting Tournament Teams (All-Star) players and coaches for all divisions will be determined by the WLL Board of Directors on an annual basis.

For the 2014 Baseball Season the method for selecting the All-Star Coaches is as follows: The President will ask each coach in the Minors and Majors Division on an individual bases if they are interested in being selected as a All-Star Coach. All interested parties will be listed on a ballot on or around May 20 2014 at a time yet to be determined at which time the coaches will conduct a blind vote. NO SOLICITATION for votes should take place prior to this date. Votes will be counted behind the concession stand with all parties in attendance. After which the board will meet and give its approval for the coaches to proceed. For Minors, the Coach with the most votes will be deemed the All-Star Manager subject to Board approval. The Coach with the next largest number of votes will have the option of becoming the “B” team coach. For Majors, coaches must notify the WLL President as to which level they want to be considered, e.g the 11/12-year-old team or the 11-year-old team.

All-Star players selected will be responsible for the cost of the uniform (not to exceed $25.00).

The WLL Board of Director will determine the amount of League funds for All-Star teams on an annual basis. The best interests of Western Little League will be considered in reaching this decision.


Field Preparation/Maintenance

The home team manager and/or coaches will chalk the field in all divisions prior to beginning of each game.

Major and Minor coaches will remove tarps and sand bags from home plate and the pitcher’s mound.

The visiting manager/or coach will rake the field in all divisions following each game and replace the tarps and sand bags on home plate and the pitcher’s mound.

Coaches involved with the first game of the day at their field are responsible for making sure a trash receptacle is obtained from the concession area.

Coaches who play the final game of the day are responsible for returning the trash receptacle at their field to the concession area.

Coaches are responsible for ensuring the removal of all trash from the dugout immediately after games.

Player/Fan Conduct

Any coach, player or spectator who is abusive in any manner will be asked to leave. This decision is solely and completely the decision of the acting Field Director.

The decisions of the Field Director (Posted at the concession stand each day) will be final.

Tobacco products, Alcohol and any NON-prescription drugs are strictly prohibited at any Western Little League function.

Schedule Changes

Changes to the game schedule must be submitted in writing to the Vice-President of the respective division at least 1 week prior to the proposed change. The Vice-President will verify that a field and umpires (if required) are secured. Once the new time and date are finalized, the respective coaches will be notified and the change will be updated to www.GRWESTERNLL.com


























LO

CA

L L

EA

GU

E U

SE

ON

LY

:

ĂĐŬŐƌŽƵŶĚĐŚĞĐŬĐŽŵƉůĞƚĞĚďǇůĞĂŐƵĞŽĸ

ĐĞƌͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŽŶͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

System)s) used for background check (m

inimum

of one must be checked):

^ĞǆKīĞŶĚĞƌZĞŐŝƐƚƌǇƌŝŵ

ŝŶĂů,ŝƐƚŽƌǇZĞĐŽƌĚƐΎ&ŝƌƐƚĚǀĂŶƚĂŐĞ

*Please be advised that if you use First Advantage and there is a name m

atch in the few states

ǁŚĞƌĞŽŶůǇŶĂŵ

ĞŵĂƚĐŚƐĞĂƌĐŚĞƐĐĂŶďĞƉĞƌĨŽƌŵ

ĞĚǇŽƵƐŚŽƵůĚŶŽƟĨǇǀŽůƵŶƚĞĞƌƐƚŚĂƚƚŚĞǇǁŝůů

ƌĞĐĞŝǀĞĂůĞƩĞƌĚŝƌĞĐƚůǇĨƌŽŵ>ĞǆŝƐEĞǆŝƐŝŶĐŽŵ

ƉůŝĂŶĐĞǁŝƚŚƚŚĞ&ĂŝƌƌĞĚŝƚZĞƉŽƌƟŶŐĐƚĐŽŶƚĂŝŶŝŶŐ

ŝŶĨŽƌŵĂƟŽŶƌĞŐĂƌĚŝŶŐĂůůƚŚĞĐƌŝŵ

ŝŶĂůƌĞĐŽƌĚƐĂƐƐŽĐŝĂƚĞĚǁŝƚŚƚŚĞŶĂŵ

ĞǁŚŝĐŚŵ

ĂǇŶŽƚŶĞĐĞƐƐĂƌŝůǇbe the league volunteer.

KŶůǇĂƩ

ĂĐŚƚŽƚŚŝƐĂƉƉůŝĐĂƟŽŶĐŽƉŝĞƐŽĨďĂĐŬŐƌŽƵŶĚĐŚĞĐŬƌĞƉŽƌƚƐƚŚĂƚƌĞǀĞĂůĐŽŶǀŝĐƟŽŶƐŽĨƚŚŝƐĂƉƉůŝĐĂƟŽŶ

>ŝƩůĞ>ĞĂŐƵĞ

® sŽůƵŶƚĞĞƌƉƉůŝĐĂƟŽŶͲϮϬϭϰŽŶŽƚƵƐĞĨŽƌŵ

ƐĨƌŽŵƉĂƐƚǇĞĂƌƐh

ƐĞĞǆƚƌĂƉĂƉĞƌƚŽĐŽŵƉůĞƚĞŝĨĂĚĚŝƟŽŶĂůƐƉĂĐĞŝƐƌĞƋƵŝƌĞĚ

WůĞĂƐĞůŝƐƚƚŚƌĞĞƌĞĨĞƌĞŶĐĞƐĂƚůĞĂƐƚŽŶĞŽĨǁŚŝĐŚŚĂƐŬŶŽǁ

ůĞĚŐĞŽĨǇŽƵƌƉĂƌƟĐŝƉĂƟŽŶĂƐĂǀŽůƵŶƚĞĞƌŝŶĂǇŽƵƚŚƉƌŽŐƌĂŵ

EĂŵ

ĞWŚŽŶĞ

ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ



^KE/d/K

EK&sK

>hEdZ/E

'/ŐŝǀĞƉĞƌŵ

ŝƐƐŝŽŶĨŽƌƚŚĞ>ŝƩůĞ>ĞĂŐƵĞŽƌŐĂŶŝǌĂƟŽŶƚŽĐŽŶĚƵĐƚďĂĐŬŐƌŽƵŶĚĐŚĞĐŬ;ƐͿŽŶŵ

ĞŶŽǁĂŶĚĂƐůŽŶŐĂƐ/ĐŽŶƟŶƵĞƚŽďĞ

ĂĐƟǀĞǁŝƚŚƚŚĞŽƌŐĂŶŝǌĂƟŽŶǁ

ŚŝĐŚŵĂǇŝŶĐůƵĚĞĂƌĞǀŝĞǁ

ŽĨƐĞǆŽīĞŶĚĞƌƌĞŐŝƐƚƌŝĞƐ;ƐŽŵĞ

of which contain nam

e only searches which m

ay result in a report being generated that ŵĂǇŽƌŵ

ĂǇŶŽƚďĞŵĞͿĐŚŝůĚĂďƵƐĞĂŶĚĐƌŝŵ

ŝŶĂůŚŝƐƚŽƌǇƌĞĐŽƌĚƐ/ƵŶĚĞƌƐƚĂŶĚƚŚĂƚŝĨĂƉƉŽŝŶƚĞĚŵ

ǇƉŽƐŝƟŽŶŝƐĐŽŶĚŝƟŽŶĂůƵƉŽŶƚŚĞůĞĂŐƵĞƌĞĐĞŝǀŝŶŐŶŽŝŶĂƉƉƌŽƉƌŝĂƚĞŝŶĨŽƌŵ

ĂƟŽŶŽŶŵǇďĂĐŬŐƌŽƵŶĚ/ŚĞƌĞďǇƌĞůĞĂƐĞĂŶĚĂŐƌĞĞƚŽŚŽůĚŚĂƌŵ

ůĞƐƐĨƌŽŵ

ůŝĂďŝůŝƚǇƚŚĞůŽĐĂů>ŝƩůĞ>ĞĂŐƵĞ>ŝƩůĞ>ĞĂŐƵĞĂƐĞďĂůů/ŶĐŽƌƉŽƌĂƚĞĚƚŚĞŽĸĐĞƌƐ

ĞŵƉůŽǇĞĞƐĂŶĚǀŽůƵŶƚĞĞƌƐƚŚĞƌĞŽĨŽƌĂŶǇŽƚŚĞƌƉĞƌƐŽŶŽƌŽƌŐĂŶŝǌĂƟŽŶƚŚĂƚŵ

ĂǇƉƌŽǀŝĚĞƐƵĐŚŝŶĨŽƌŵ

ĂƟŽŶ/ĂůƐŽƵŶĚĞƌƐƚĂŶĚƚŚĂƚƌĞŐĂƌĚůĞƐƐŽĨƉƌĞǀŝŽƵƐĂƉƉŽŝŶƚŵĞŶƚƐ>ŝƩůĞ

>ĞĂŐƵĞŝƐŶŽƚŽďůŝŐĂƚĞĚƚŽĂƉƉŽŝŶƚŵĞƚŽĂǀŽůƵŶƚĞĞƌƉŽƐŝƟŽŶ/ĨĂƉƉŽŝŶƚĞĚ/ƵŶĚĞƌƐƚĂŶĚ

ƚŚĂƚƉƌŝŽƌƚŽƚŚĞĞǆƉŝƌĂƟŽŶŽĨŵǇƚĞƌŵ

/ĂŵƐƵďũĞĐƚƚŽƐƵƐƉĞŶƐŝŽŶďǇƚŚĞWƌĞƐŝĚĞŶƚĂŶĚ

ƌĞŵŽǀĂůďǇƚŚĞŽĂƌĚŽĨŝƌĞĐƚŽƌƐĨŽƌǀŝŽůĂƟŽŶŽĨ>ŝƩůĞ>ĞĂŐƵĞƉŽůŝĐŝĞƐŽƌƉƌŝŶĐŝƉůĞƐ

ƉƉůŝĐĂŶƚ^ŝŐŶĂƚƵƌĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺ

/ĨDŝŶŽƌWĂƌĞŶƚ^ŝŐŶĂƚƵƌĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺ

ƉƉůŝĐĂŶƚEĂŵ

Ğ;ƉůĞĂƐĞƉƌŝŶƚŽƌƚǇƉĞͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺEKddŚĞůŽĐĂů>ŝƩůĞ>ĞĂŐƵĞĂŶĚ>ŝƩůĞ>ĞĂŐƵĞĂƐĞďĂůů/ŶĐŽƌƉŽƌĂƚĞĚǁ

ŝůůŶŽƚĚŝƐĐƌŝŵŝŶĂƚĞ

ĂŐĂŝŶƐƚĂŶǇƉĞƌƐŽŶŽŶƚŚĞďĂƐŝƐŽĨƌĂĐĞĐƌĞĞĚĐŽůŽƌŶĂƟŽŶĂůŽƌŝŐŝŶŵĂƌŝƚĂůƐƚĂƚƵƐŐĞŶĚĞƌƐĞǆƵĂů

ŽƌŝĞŶƚĂƟŽŶŽƌĚŝƐĂďŝůŝƚǇ

KWzK

&s>/'KsZE

DE

d/^^hW,K

dK/E

d/&/d/KED

h^d

dd,dKK

DW>dd,/^WW>/d/K

E

EĂŵ

ĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŝƚǇͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

StateͺͺͺͺͺͺͺͺͺZipͺͺͺͺͺͺͺͺͺͺͺͺͺ^ŽĐŝĂů^ĞĐƵƌŝƚǇη;ŵ

ĂŶĚĂƚŽƌǇǁŝƚŚ&ŝƌƐƚĚǀĂŶƚĂŐĞŽƌƵƉŽŶƌĞƋƵĞƐƚͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĞůůWŚŽŶĞƵƐŝŶĞƐƐWŚŽŶĞͲŵ

ĂŝůĚĚƌĞƐƐĂƚĞŽĨŝƌƚŚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKĐĐƵƉĂƟŽŶͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ŵƉůŽǇĞƌͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺSpecial professional training, skills, hobbies:ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŽŵ

ŵƵŶŝƚǇĂĸ

ůŝĂƟŽŶƐ;ůƵďƐ^ĞƌǀŝĐĞKƌŐĂŶŝǌĂƟŽŶƐĞƚĐͿ

ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺWƌĞǀŝŽƵƐǀŽůƵŶƚĞĞƌĞǆƉĞƌŝĞŶĐĞ;ŝŶĐůƵĚŝŶŐďĂƐĞďĂůůƐŽŌďĂůůĂŶĚǇĞĂƌͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŽǇŽƵŚĂǀĞĐŚŝůĚƌĞŶŝŶƚŚĞƉƌŽŐƌĂŵ

zĞƐEŽ

/ĨǇĞƐůŝƐƚĨƵůůŶĂŵĞĂŶĚ

ǁŚĂƚůĞǀĞůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

^ƉĞĐŝĂůĞƌƟĮĐĂƟŽŶ;WZDĞĚŝĐĂůĞƚĐͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

ŽǇŽƵŚĂǀĞĂǀĂůŝĚĚƌŝǀĞƌƐůŝĐĞŶƐĞzĞƐEŽ

ƌŝǀĞƌƐ>ŝĐĞŶƐĞηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺStateͺͺͺͺͺͺͺͺͺͺͺ,ĂǀĞǇŽƵĞǀĞƌďĞĞŶĐŽŶǀŝĐƚĞĚŽĨŽƌƉůĞĂĚŐƵŝůƚǇƚŽĂŶǇĐƌŝŵ

Ğ;ƐͿŝŶǀŽůǀŝŶŐŽƌĂŐĂŝŶƐƚĂŵ

ŝŶŽƌzĞƐ

EŽ

/ĨǇĞƐĚĞƐĐƌŝďĞĞĂĐŚŝŶĨƵůůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺƌĞƚŚĞƌĞĂŶǇĐƌŝŵ

ŝŶĂůĐŚĂƌŐĞƐƉĞŶĚŝŶŐĂŐĂŝŶƐƚǇŽƵƌĞŐĂƌĚŝŶŐĂŶǇĐƌŝŵĞ;ƐͿŝŶǀŽůǀŝŶŐ

ŽƌĂŐĂŝŶƐƚĂŵŝŶŽƌzĞƐE

Ž/ĨǇĞƐĚĞƐĐƌŝďĞĞĂĐŚŝŶĨƵůůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ,ĂǀĞǇŽƵĞǀĞƌďĞĞŶƌĞĨƵƐĞĚƉĂƌƟĐŝƉĂƟŽŶŝŶĂŶǇŽƚŚĞƌǇŽƵƚŚƉƌŽŐƌĂŵ

ƐzĞƐEŽ

/ĨǇĞƐĞǆƉůĂŝŶͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ/Ŷǁ

ŚŝĐŚŽĨƚŚĞĨŽůůŽǁŝŶŐǁ

ŽƵůĚǇŽƵůŝŬĞƚŽƉĂƌƟĐŝƉĂƚĞ;ŚĞĐŬŽŶĞŽƌŵŽƌĞͿ

>ĞĂŐƵĞKĸĐŝĂů

ŽĂĐŚhŵƉŝƌĞ

&ŝĞůĚDĂŝŶƚĞŶĂŶĐĞ

DĂŶĂŐĞƌ

^ĐŽƌĞŬĞĞƉĞƌŽŶĐĞƐƐŝŽŶ^ƚĂŶĚ

KƚŚĞƌ

ϭͳϬϮͳϭϭͳsK>h

EdZWW>/d/K

EϯϮϴϭϭ


If you filled out a volunteer application last year and your league uses the background check tools provided by Little League International, please fill out the returning volunteer application. O

therwise, please use the standard

volunteer application.

You must provide the inform

ation to all the questions in this section

In which of the follow

ing would you like to volunteer? (Check one or m

ore)

League Offi

cialM

anagerCoach

Um

pireField M

aintenance

Score KeeperConcession Stand

Other: __________________________

AS A CON

DITIO

N O

F VOLU

NTEERIN

G, I give perm

ission for the Little League organization to conduct background check(s) on m

e now and as long as I continue to be active w

ith the organization, which m

ay include a review of

sex offender registries (some of w

hich contain name only searches w

hich may result in a report being generated

that may or m

ay not be me), child abuse and crim

inal history records. I understand that, if appointed, my position

is conditional upon the league receiving no inappropriate information on m

y background. I hereby release and agree to hold harm

less from liability the local Little League, Little League Baseball, Incorporated, the offi

cers, em

ployees and volunteers thereof, or any other person or organization that may provide such inform

ation. I also understand that, regardless of previous appointm

ents, 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 D

irectors for violation of Little League policies or principles.

Applicant Nam

e (please print or type): ___________________________________________________

Applicant Signature: ________________________________________D

ate: ____________________

If Minor —

Parent Signature: _________________________________D

ate: ____________________

NOTE: The local Little League and Little League Baseball, Incorporated w

ill not discriminate against any person on the

basis of race, creed, color, national origin, martial status, gender, sexual orientation or disability.

Are there any criminal charges pending against you regarding any crim

e(s)involving or against a m

inor?

If Yes, describe each in full: ____________________________________________________ __________________________________________________________________________

Yes N

o

Have you ever been refused participation in any other youth program

?If Yes, explain: _______________________________________________________________

Yes N

o

Little League® “Returning” Volunteer Application - 2014D

o not use forms from

past years. Use extra paper to com

plete if additional space is required.

Please update only the information in this section w

hich has changed since last year.

Nam

e: _______________________________________________________________________ Address: _____________________________________________________________________City: ____________________________________________H

ome Phone: ______________________________

E-Mail Address: _______________________________________________________________

Driver’s License #: _________________________________________________

Occupation: __________________________________________________________________

Employer: ____________________________________________________________________

Address: _____________________________________________________________________

State: _______ ZIP: ___________

State: _______

Cell or Work Phone: _________________

Please list three references, at least one of which has know

ledge of your participation as a volunteer in a youth program

:

________________________________________________ / __________________________________________________________________________ / __________________________________________________________________________ / __________________________

Nam

e / Phone:

____________________________________________________________________________Special professional training, skills, hobbies:

____________________________________________________________________________Special Certifications (CPR, M

edical, etc):

____________________________________________________________________________Special Affi

liations (Clubs, Service Organizations, etc):

____________________________________________________________________________

____________________________________________________________________________Previous volunteer experience (including baseball/softball and year(s)):

LOCA

L LEAGU

E USE O

NLY:

Background Check completed by league offi

cer ________________________________________________on _____________________________________________________________________________________

System(s) used for background check (m

inimum

of one must be checked):

Sex Offender Registry

Criminal H

istory Records*First Advantage

*Please be advised that if you use First Advantage and there is a name m

atch in the few states w

here only name

match searches can be perform

ed you should notify volunteers that they will recieve a letter directly from

First Advantage in com

pliance with the Fair Credit Reporting Act containing inform

ation regarding all the criminal

association with the nam

e, which m

ay not necessarily be the league volunteer.

Only attach to this application copies of background check

reports that reveal convictions of this application.

Have you ever been convicted or plead guilty to any crim

e(s) involving or against a minor?

If Yes, describe each in full: ____________________________________________________ __________________________________________________________________________

Yes N

o


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.


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 SOFTBALLACCIDENT NOTIFICATION FORM

INSTRUCTIONS

7KLVIRUPPXVWEHFRPSOHWHGE\SDUHQWVLIFODLPDQWLVXQGHU\HDUVRIDJHDQGDOHDJXHRI¿FLDODQGIRUZDUGHGWR/LWWOH/HDJXH+HDGTXDUWHUVZLWKLQGD\VDIWHUWKHDFFLGHQW$SKRWRFRS\RIWKLVIRUPVKRXOGEHPDGHDQGNHSWE\WKHFODLPDQWSDUHQW,QLWLDOPHGLFDOGHQWDOWUHDWPHQWPXVWEHUHQGHUHGZLWKLQGD\VRIWKH/LWWOH/HDJXHDFFLGHQW

,WHPL]HGELOOVLQFOXGLQJGHVFULSWLRQRIVHUYLFHGDWHRIVHUYLFHSURFHGXUHDQGGLDJQRVLVFRGHVIRUPHGLFDOVHUYLFHVVXSSOLHVDQGRURWKHUGRFXPHQWDWLRQUHODWHGWRFODLPIRUEHQH¿WVDUHWREHSURYLGHGZLWKLQGD\VDIWHUWKHDFFLGHQWGDWH,QQRHYHQWVKDOOVXFKSURRIEHIXUQLVKHGODWHUWKDQPRQWKVIURPWKHGDWHWKHPHGLFDOH[SHQVHZDVLQFXUUHG

:KHQRWKHULQVXUDQFHLVSUHVHQWSDUHQWVRUFODLPDQWPXVWIRUZDUGFRSLHVRIWKH([SODQDWLRQRI%HQH¿WVRU1RWLFH/HWWHURI'HQLDOIRUHDFKFKDUJHGLUHFWO\WR/LWWOH/HDJXH+HDGTXDUWHUVHYHQLIWKHFKDUJHVGRQRWH[FHHGWKHGHGXFWLEOHRIWKHSULPDU\LQVXUDQFHSURJUDP

3ROLF\SURYLGHVEHQH¿WVIRUHOLJLEOHPHGLFDOH[SHQVHVLQFXUUHGZLWKLQZHHNVRIWKHDFFLGHQWVXEMHFWWR([FHVV&RYHUDJHDQG([FOXVLRQSURYLVLRQVRIWKHSODQ

LimitedGHIHUUHGPHGLFDOGHQWDOEHQH¿WVPD\EHDYDLODEOHIRUQHFHVVDU\WUHDWPHQWLQFXUUHGDIWHUZHHNV5HIHUWRLQVXUDQFHEURFKXUHSURYLGHGWRWKHOHDJXHSUHVLGHQWRUFRQWDFW/LWWOH/HDJXH+HDGTXDUWHUVZLWKLQWKH\HDURILQMXU\

$FFLGHQW&ODLP)RUPPXVWEHIXOO\FRPSOHWHGLQFOXGLQJ6RFLDO6HFXULW\1XPEHU661IRUSURFHVVLQJ

/HDJXH1DPH /HDJXH,'

1DPHRI,QMXUHG3HUVRQ&ODLPDQW 661 6H[$JH'DWHRI%LUWK00''<<

1DPHRI3DUHQW*XDUGLDQLI&ODLPDQWLVD0LQRU +RPH3KRQH,QF$UHD&RGH %XV3KRQH,QF$UHD&RGH( ) ( )

$GGUHVVRI&ODLPDQW $GGUHVVRI3DUHQW*XDUGLDQLIGLIIHUHQW

7KH/LWWOH/HDJXH0DVWHU$FFLGHQW3ROLF\SURYLGHVEHQH¿WVLQexcessRIEHQH¿WVIURPRWKHULQVXUDQFHSURJUDPVVXEMHFWWRDGHGXFWLEOHSHULQMXU\³2WKHULQVXUDQFHSURJUDPV´LQFOXGHIDPLO\¶VSHUVRQDOLQVXUDQFHVWXGHQWLQVXUDQFHWKURXJKDVFKRRORULQVXUDQFHWKURXJKDQHPSOR\HUIRUHPSOR\HHVDQGIDPLO\PHPEHUV3OHDVH&+(&.WKHDSSURSULDWHER[HVEHORZ,I<(6IROORZLQVWUXFWLRQDERYH

,KHUHE\FHUWLI\WKDW,KDYHUHDGWKHDQVZHUVWRDOOSDUWVRIWKLVIRUPDQGWRWKHEHVWRIP\NQRZOHGJHDQGEHOLHIWKHLQIRUPDWLRQFRQWDLQHGLVFRPSOHWHDQGFRUUHFWDVKHUHLQJLYHQ,XQGHUVWDQGWKDWLWLVDFULPHIRUDQ\SHUVRQWRLQWHQWLRQDOO\DWWHPSWWRGHIUDXGRUNQRZLQJO\IDFLOLWDWHDIUDXGDJDLQVWDQLQVXUHUE\VXEPLWWLQJDQDSSOLFDWLRQRU¿OLQJDFODLPFRQWDLQLQJDIDOVHRUGHFHSWLYHVWDWHPHQWV6HH5HPDUNVVHFWLRQRQUHYHUVHVLGHRIIRUP,KHUHE\DXWKRUL]HDQ\SK\VLFLDQKRVSLWDORURWKHUPHGLFDOO\UHODWHGIDFLOLW\LQVXUDQFHFRPSDQ\RURWKHURUJDQL]DWLRQLQVWLWXWLRQRUSHUVRQWKDWKDVDQ\UHFRUGVRUNQRZOHGJHRIPHDQGRUWKHDERYHQDPHGFODLPDQWRURXUKHDOWKWRGLVFORVHZKHQHYHUUHTXHVWHGWRGRVRE\/LWWOH/HDJXHDQGRU1DWLRQDO8QLRQ)LUH,QVXUDQFH&RPSDQ\RI3LWWVEXUJK3D$SKRWRVWDWLFFRS\RIWKLVDXWKRUL]DWLRQVKDOOEHFRQVLGHUHGDVHIIHFWLYHDQGYDOLGDVWKHRULJLQDO

'DWH

'DWH

&ODLPDQW3DUHQW*XDUGLDQ6LJQDWXUH,QDWZRSDUHQWKRXVHKROGERWKSDUHQWVPXVWVLJQWKLVIRUP

&ODLPDQW3DUHQW*XDUGLDQ6LJQDWXUH

'DWHRI$FFLGHQW 7LPHRI$FFLGHQW 7\SHRI,QMXU\

$0 30'HVFULEHH[DFWO\KRZDFFLGHQWKDSSHQHGLQFOXGLQJSOD\LQJSRVLWLRQDWWKHWLPHRIDFFLGHQW

&KHFNDOODSSOLFDEOHUHVSRQVHVLQeachFROXPQ%$6(%$//62)7%$//&+$//(1*(57$'1'6($621

&+$//(1*(5 7%$// 0,125 /,77/(/($*8(-81,25 6(1,25 %,*/($*8(

3/$<(50$1$*(5&2$&+92/817((5803,5(3/$<(5$*(172)),&,$/6&25(.((3(56$)(7<2)),&(592/817((5:25.(5

75<287635$&7,&(6&+('8/('*$0(75$9(/7275$9(/)52072851$0(1727+(5'HVFULEH

63(&,$/(9(17 127*$0(663(&,$/*$0(6 6XEPLWDFRS\RI \RXUDSSURYDOIURP /LWWOH/HDJXH ,QFRUSRUDWHG

Send Completed Form To:/LWWOH/HDJXH®,QWHUQDWLRQDO865RXWH+Z\32%R[:LOOLDPVSRUW3$Accident Claim Contact Numbers:3KRQH)D[

3$57

)HPDOH 0DOH

'RHVWKHLQVXUHG3HUVRQ3DUHQW*XDUGLDQKDYHDQ\LQVXUDQFHWKURXJK (PSOR\HU3ODQ <HV 1R 6FKRRO3ODQ <HV 1R,QGLYLGXDO3ODQ <HV 1R 'HQWDO3ODQ <HV 1R

INTERMEDIATE (50/70) (11-13)

JUNIOR (12-14)SENIOR (13-16)BIG (14-18)

(4-18)(4-7)(6-12)


For Residents of California:$Q\SHUVRQZKRNQRZLQJO\SUHVHQWVDIDOVHRUIUDXGXOHQWFODLPIRUWKHSD\PHQWRIDORVVLVJXLOW\RIDFULPHDQGPD\EHVXEMHFWWR¿QHVDQGFRQ¿QHPHQWLQVWDWHSULVRQ

For Residents of New York:$Q\SHUVRQZKRNQRZLQJO\DQGZLWKWKHLQWHQWWRGHIUDXGDQ\LQVXUDQFHFRPSDQ\RURWKHUSHUVRQ¿OHVDQDSSOLFDWLRQIRULQVXUDQFHRUVWDWHPHQWRIFODLPFRQWDLQLQJDQ\PDWHULDOO\IDOVHLQIRUPDWLRQRUFRQFHDOVIRUWKHSXUSRVHRIPLVOHDGLQJLQIRUPDWLRQFRQFHUQLQJDQ\IDFWPDWHULDOWKHUHWRFRPPLWVDIUDXGXOHQWLQVXUDQFHDFWZKLFKLVDFULPHDQGVKDOODOVREHVXEMHFWWRDFLYLOSHQDOW\QRWWRH[FHHG¿YHWKRXVDQGGROODUVDQGWKHVWDWHGYDOXHRIWKHFODLPIRUHDFKVXFKYLRODWLRQ

For Residents of Pennsylvania:$Q\SHUVRQZKRNQRZLQJO\DQGZLWKLQWHQWWRGHIUDXGDQ\LQVXUDQFHFRPSDQ\RURWKHUSHUVRQ¿OHVDQDSSOLFDWLRQIRULQVXUDQFHRUVWDWHPHQWRIFODLPFRQWDLQLQJDQ\PDWHULDOO\IDOVHLQIRUPDWLRQRUFRQFHDOVIRUWKHSXUSRVHRIPLVOHDGLQJLQIRUPDWLRQFRQFHUQLQJDQ\IDFWPDWHULDOWKHUHWRFRPPLWVDIUDXGXOHQWLQVXUDQFHDFWZKLFKLVDFULPHDQGVXEMHFWVVXFKSHUVRQWRFULPLQDODQGFLYLOSHQDOWLHV

For Residents of All Other States:$Q\SHUVRQZKRNQRZLQJO\SUHVHQWVDIDOVHRUIUDXGXOHQWFODLPIRUSD\PHQWRIDORVVRUEHQH¿WRUNQRZLQJO\SUHVHQWVIDOVHLQIRUPDWLRQLQDQDSSOLFDWLRQIRULQVXUDQFHLVJXLOW\RIDFULPHDQGPD\EHVXEMHFWWR¿QHVDQGFRQ¿QHPHQWLQSULVRQ

PART 2 - LEAGUE STATEMENT (Other than Parent or Claimant)1DPHRI/HDJXH 1DPHRI,QMXUHG3HUVRQ&ODLPDQW /HDJXH,'1XPEHU

1DPHRI/HDJXH2I¿FLDO 3RVLWLRQLQ/HDJXH

$GGUHVVRI/HDJXH2I¿FLDO 7HOHSKRQH1XPEHUV,QF$UHD&RGHV5HVLGHQFH %XVLQHVV )D[

:HUH\RXDZLWQHVVWRWKHDFFLGHQW" <HV 1R3URYLGHQDPHVDQGDGGUHVVHVRIDQ\NQRZQZLWQHVVHVWRWKHUHSRUWHGDFFLGHQW

&KHFNWKHER[HVIRUDOODSSURSULDWHLWHPVEHORZ$WOHDVWRQHLWHPLQHDFKFROXPQPXVWEHVHOHFWHGPOSITION WHEN INJURED 67 1' 5' %$77(5 %(1&+ %8//3(1 &$7&+(5 &2$&+ &2$&+,1*%2; '8*287 0$1$*(5 21'(&. 287),(/' 3,7&+(5 5811(5 6&25(.((3(5 6+2576723 72)520*$0( 803,5( 27+(5 81.12:1 :$50,1*83

INJURY $%5$6,21 %,7(6 &21&866,21 &21786,21 '(17$/ ',6/2&$7,21 ',60(0%(50(17 (3,3+<6(6 )$7$/,7< )5$&785( +(0$720$ +(0255+$*( /$&(5$7,21 381&785( 583785( 635$,1 6816752.( 27+(5 81.12:1 3$5$/<6,6 3$5$3/(*,&

PART OF BODY $%'20(1 $1./( $50 %$&. &+(67 ($5 (/%2: (<( )$&( )$7$/,7< )227 +$1' +($' +,3 .1(( /(* /,36 0287+ 1(&. 126( 6+28/'(5 6,'( 7((7+ 7(67,&/( :5,67 81.12:1 ),1*(5

CAUSE OF INJURY %$77('%$// %$77,1* &$7&+,1* &2//,',1* &2//,',1*:,7+)(1&( )$//,1* +,7%<%$7 +256(3/$< 3,7&+('%$// 5811,1* 6+$532%-(&7 6/,',1* 7$**,1* 7+52:,1* 7+52:1%$// 27+(5 81.12:1

'RHV\RXUOHDJXHXVHEUHDNDZD\EDVHVRQ $// 620( 121( RI\RXU¿HOGV"'RHV\RXUOHDJXHXVHEDWWLQJKHOPHWVZLWKDWWDFKHGIDFHJXDUGV" <(6 12,I<(6DUHWKH\ 0DQGDWRU\ RU 2SWLRQDO $WZKDWOHYHOVDUHWKH\XVHG",KHUHE\FHUWLI\WKDWWKHDERYHQDPHGFODLPDQWZDVLQMXUHGZKLOHFRYHUHGE\WKH/LWWOH/HDJXH%DVHEDOO$FFLGHQW,QVXUDQFH3ROLF\DWWKHWLPHRIWKHUHSRUWHGDFFLGHQW,DOVRFHUWLI\WKDWWKHLQIRUPDWLRQFRQWDLQHGLQWKH&ODLPDQW¶V1RWL¿FDWLRQLVWUXHDQGFRUUHFWDVVWDWHGWRWKHEHVWRIP\NQRZOHGJH'DWH /HDJXH2I¿FLDO6LJQDWXUH


Activities/Reporting A Safety Awareness Program’s

Incident/Injury Tracking Report

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 (5-8) Minor (7-12) Major (9-12) Junior (13-14) Senior (14-16) Big League (16-18)

C.) Tryout Practice Game Tournament Special Event Travel to 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 B.) Adjacent to Playing Field D.) Off Ball Field Base Path: Running or Sliding Seating Area Travel: Hit by Ball: Pitched or Thrown or Batted Parking Area Car or Bike or Collision with: Player or Structure C.) Concession Area 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 Little League purposes only, to report safety hazards, unsafe practices and/or to contribute posi-tive ideas in order to improve league safety. When an accident occurs, obtain as much information as possible.For all claims or injuries which could become claims, please fill out and turn in the official Little League BaseballAccident Notification Form available from your league president and send to Little League Headquarters inWilliamsport (Attention: Dan Kirby, Risk Management Department). Also, provide your District Safety Officer witha copy for District files. All personal injuries should be reported to Williamsport as soon as possible.Prepared By/Position: ____________________________________ Phone Number: (_____) _____________Signature: _____________________________________________ Date: _____________________________

Intermediate (50/70) (11-13)

Junior (12-14) Senior (13-16) Big League (15-18)(4-7) (7-11)

For Local League Use Only

dŚŝƐĨŽƌŵŝƐĨŽƌůŽĐĂů>ŝƩůĞ>ĞĂŐƵĞƵƐĞŽŶůǇ;ƐŚŽƵůĚŶŽƚďĞƐĞŶƚƚŽ>ŝƩůĞ>ĞĂŐƵĞ/ŶƚĞƌŶĂƟŽŶĂůͿdŚŝƐĚŽĐƵŵĞŶƚƐŚŽƵůĚďĞƵƐĞĚƚŽĞǀĂůƵĂƚĞƉŽƚĞŶƟĂůƐĂĨĞƚǇŚĂǌĂƌĚƐƵŶƐĂĨĞƉƌĂĐƟĐĞƐĂŶĚŽƌƚŽĐŽŶƚƌŝďƵƚĞƉŽƐŝƟǀĞŝĚĞĂƐŝŶŽƌĚĞƌƚŽŝŵƉƌŽǀĞůĞĂŐƵĞƐĂĨĞƚǇtŚĞŶĂŶĂĐĐŝĚĞŶƚŽĐĐƵƌƐŽďƚĂŝŶĂƐŵƵĐŚŝŶĨŽƌŵĂƟŽŶĂƐƉŽƐƐŝďůĞ&ŽƌĂůůĐĐŝĚĞŶƚĐůĂŝŵƐŽƌŝŶũƵƌŝĞƐƚŚĂƚĐŽƵůĚďĞĐŽŵĞĐůĂŝŵƐƚŽĂŶǇĞůŝŐŝďůĞƉĂƌƟĐŝƉĂŶƚƵŶĚĞƌƚŚĞĐ-ĐŝĚĞŶƚ/ŶƐƵƌĂŶĐĞƉŽůŝĐǇ ƉůĞĂƐĞĐŽŵƉůĞƚĞƚŚĞĐĐŝĚĞŶƚEŽƟĮĐĂƟŽŶůĂŝŵĨŽƌŵĂǀĂŝůĂďůĞĂƚŚƩƉǁǁǁůŝƩůĞůĞĂŐƵĞŽƌŐƐƐĞƚƐĨŽƌŵƐͺƉƵďƐĂƐĂƉĐĐŝĚĞŶƚůĂŝŵ&ŽƌŵƉĚĨĂŶĚƐĞŶĚƚŽ>ŝƩůĞ>ĞĂŐƵĞ/ŶƚĞƌŶĂƟŽŶĂů&ŽƌĂůůŽƚŚĞƌĐůĂŝŵƐƚŽŶŽŶͲĞůŝŐŝďůĞƉĂƌƟĐŝƉĂŶƚƐƵŶĚĞƌƚŚĞĐĐŝĚĞŶƚƉŽůŝĐǇŽƌĐůĂŝŵƐƚŚĂƚŵĂǇƌĞƐƵůƚŝŶůŝƟŐĂƟŽŶƉůĞĂƐĞĮůůŽƵƚƚŚĞ'ĞŶĞƌĂů>ŝĂďŝůŝƚǇůĂŝŵĨŽƌŵĂǀĂŝůĂďůĞŚĞƌĞŚƩƉǁǁǁůŝƩůĞůĞĂŐƵĞŽƌŐƐ-ƐĞƚƐĨŽƌŵƐͺƉƵďƐĂƐĂƉ'>ůĂŝŵ&ŽƌŵƉĚĨ

2014 Western Little League Safety Manual...Mushball: Jeff Barrett 616.822.6374 [email protected] Softball Jr/Sr: Bob Wynsma 616.893.2804 [email protected] Softball Min/Maj: Brad VanManen

Documents