Medical release/waiver form

 

VONEGYPT SOCCER ACADEMY MEDICAL RELEASE/WAIVER FORM EXPRESS ASSUMPTION OF RISK ASSOCIATED WITH SOCCER TRAINING, ATHLETIC DEVELOPMENT, VENUE USE AND RELATED ACTIVITIES. I, ________________________________________________ do hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with soccer training and development, transportation of equipment related to the activities, and traveling to and from training sites in which I am about to engage. Inherent hazards and risks include but are not limited to: 1. Risk of injury from the activity and equipment utilized is significant including the potential for broken bones, severe injuries to the head, neck, and back or other bodily injuries that my result in permanent disability and death. 2. Possible equipment failure and/or malfunction or misuse of my own or others’ equipment. 3. I AGREE THAT I WILL WEAR APPROVED PROTECTIVE GEAR AS DECREED BY THE GOVERNING BODY OF THE SPORT I AM PARTICIPATING IN. However, protective gear cannot guarantee the participant’s safety. I further agree that no helmet can protect the wearer against all potential head injuries or prevent injury to the wearer’s face, neck or spinal cord. 4. Variation and/or steepness of terrain, variation or changes in surfaces including but not limited to snow surfaces, ice, bare spots, rocks, stumps, debris, cliffs, trees, fences, posts, light poles, signs, buildings, roads, walkways, ramps, rails, stairs, pyramids, manual pads, bowls, half-pipes, jumps, padded and non padded barriers, other persons, and other natural and man-made hazards. 5. My own negligence and/or the negligence of others, including but not limited to operator error and guide decision making including misjudging terrain, weather, riding surfaces or other obstacles. 6. Exposure to the elements and temperature extremes may result if frost nip, frost bite, heat exhaustion, heat stroke, sunburn, hypothermia, and dehydration. 7. Dangers associated with exposure to natural elements include but are not limited to avalanche, rock fall, inclement weather, thunder, and lighting, severe and or varied wind, temperature, and other weather conditions. 8. Accidents or illness occurring in remote places where there are no available medical facilities. 9. Fatigue, exhaustion, chill, and/or dizziness, which may diminish my/our reaction time and increase the risk of accident. 10. Impact or collision with other athletes, spectators, facility employees, pedestrians, motor vehicles, and cyclists. *I understand the description of these risks is not complete and unknown or unanticipated risks may result in injury, illness, or death. RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT In consideration for being permitted to participate in the above described activity(ies) and related activities, I hereby agree, acknowledge and appreciate that: 1. I HEREBY RELEASE AND HOLD HARMLESS WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY NEGLIGENCE OR OTHERWISE, Nicholas vonEgypt, vonEgypt Soccer Academy, and its coaches herein referred to as releasees. 2. To release the releasees, their officers, directors, employees, representatives, agents, contractors, and volunteers from liability and responsibility whatsoever and for any claims or causes of action that I, my estate, heirs, survivors, executors, or assigns may have for personal injury, property damage, or wrongful death arising from the above activities whether caused by active or passive negligence of the releasees or otherwise. By executing this document, I agree to hold the releasees harmless and indemnify them in conjunction with any injury, disability, death, or loss or damage to person or property that may occur as a result of my engaging in the above activities. 3. By entering into this Agreement, I am not relying on any oral or written representation or statements made by the releasees, other than what is set forth in this Agreement. 4. This agreement shall apply to any and all injury, disability, death, or loss or damage to person or property occurring at any time after the execution of this agreement. AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT The applicant/participant has received a physical examination by a physician and has been found physically capable of participating in the Soccer training programs. I hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the applicant/ participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. AUTHORIZATION FOR PHOTO/IMAGE/CONVERSATIONAL RELEASE By signing this agreement I agree to have my likeness, photo and/or conversation used in positive marketing and promotional usage, printed and/or digital format, at vonEgypt Soccer Academy’s discretion. This release shall be binding to the fullest extent permitted by law. If any provision of this release is found to be unenforceable, the remaining terms shall be enforceable. I HAVE READ THIS RELEASE OF LIABILITY, ASSUMPTION OF RISK AGREEMENT AND AUTHORIZATION FOR MEDICAL TREATMENT, I FULLY UNDERSTAND ITS TERMS, I UNDERSTAND THAT I HAVE GIVEN UP LEGAL RIGHTS BY SIGNING IT, AND I SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Signature of Participant Name of Participant (Please Print) Date FOR PARTICIPANTS OF MINORITY AGE: This is to certify that I, as Parent, Guardian, Temporary Guardian with legal responsibility for this participant, do consent and agree not only to his/her release of all Releasees, but also to release and indemnify the Releasees from any and all liabilities incident to his/her involvement in these programs for myself, my heirs, assigns, and next of kin. Signature of Parent or Adult Legal Guardian Name of Parent or Adult Legal Guardian (Please Print) Date If Participant is a Minor, and by their signature, they on my behalf release all claims that both they and I have.