CONCUSSION AWARENESS RELEASE
(ADAPTED FROM THE NTERNATIONAL CONFEREANCE ON CONCUSSION IN SPORT)
A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications, including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully spear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention immediately.
Observable symptoms may include but are not limited to one or more of the following:
headaches, neck pain, amnesia, nausea, vomiting, “Pressure in the head,” drowsiness, feelings of balance problems, dizziness blurred, double or fuzzy vision, sensitivity to light or noise, drowsiness, feeling sluggish or slowed down, feeling “ foggy” or “groggy,” irritability, confusion, emotional, fatigue, low energy, sadness, anxiety, poor concentration, poor memory, repeating the same questions or comments, appearing dazed, answers questions slowly ,vacant facial expressions, forgets plays, forgets common moves, clumsy, uncoordinated, forgetful, slurred speech, behavior or personality changes, amnesia, seizures, convulsions, loss of consciousness, a change in typical behavior or personality
Athletes with the signs and symptoms of concussion should be removed from play. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. Multiple concussions can lead to prolonged recovery, or even severe brain swelling (second impact syndrome), with devastating and even fatal consequences. It is well known that adolescent or teenage athletes will often under report symptoms of injuries; concussions are not an exception. So, parents are advised to educate themselves concerning head injuries and concussions, to better protect their child-athlete’s safety.
Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for, at minimum, several hours. A youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time AND may not return to play until the athlete is evaluated by a licensed health care provider trained in the evaluation and management of concussion, AND received written clearance to return to play from that health care provider.
You must inform your child’s coach, in person and in writing, if you think that your child has any sign of a concussion. take _________________ takes concussions very seriously, and although this form is not required in all states at this time, our coaches and trainers have been educated on how to recognize the symptoms of head injury while they participate in soccer events, however they are not experts at such. Parents know their child’s behavior best, so it is the parents’ responsibility to inform the staff of their observations concerning any injury to their child, especially a head injury, whether that injury occurs on or off the field.
For current and up-to-date information on concussions you can go to: http://www.cdc.gov/ConcussionInYouthSports/
Goalies must wear a form of FIFA approved, US Soccer approved, and ASTM approved protective headgear. Although protective headgear is not currently required for play, all other field players are highly advised to wear protective headgear for their own personal protection and safety. Protective headgear for soccer is carried at all major sporting goods stores and may be easily purchased online through Amazon and most other online sporting goods retailers.
_________________________________________________________________________ _____________________ Player’s name printed Player’s signature Date
______________________________________________________________________________________________ Parent/legal guardian’s name printed Parent/legal guardian’s signature Date
ASSUMPTION OF THE RISK, WAIVER, INDEMNIFICATION AND RELEASE OF LIABILITY AGRREEMENT
In consideration of my minor child/ward ___________________________ (“my child”) being allowed to participate in this sports program, including all of its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:
- The risk of serious injury from the sports activities involved in this program is always present due to the nature of the sport (s); and
- I fully understand that head injuries are an inherent part of the risks involved with playing soccer and any other sporting activity; and
- FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility and risk for my child’s participation in the program; and
- I further grant ________________ and ________________, its coaches, assistant coaches, managers, treasurers, staff, agents, assigns and employees the right to photograph or video my dependent and use the photo and/or other digital reproduction of him/her or other reproduction of his/her physical likeness for publication processes, whether electronic, print, digital or electronic publishing via the Internet. I fully understand and accept this as part of the participation in the program; and
- I agree that my child may be transported by bus and/or coaches’ vehicle, and/or assistant coaches’ vehicle, and or managers’ vehicle, and/or team parents’ vehicle, and/or camp’s vehicle, and/or staffs’ vehicle, and/or parents’ vehicle to an off-site location for games, practices, functions, events, or for emergency medical treatment. I fully understand and accept this as part of the participation in this program; and
- I willingly agree to comply with the program’s stated and customary terms and conditions for my child’s participation. If, however, I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from participation and bring such to the attention of the nearest official immediately; and
- I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS the entire ______________and ____________ organizations, not for profit companies formed under the laws of the State of California, which includes but is not limited to, its coaches, assistant coaches, treasurers, managers, staff, affiliates, officers, officials, agents, assigns and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for activity (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, FINANCIAL LOSS, OR LOSS OR DAMAGE TO PERSON OR PROPERTY, ARISING FROM THE ACTS OF THE UNDERSIGNED AND/OR THEIR PARTICPATING PLAYER.
- I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS the entire _________________and _________________ organizations, not for profit companies formed under the laws of the State of California, which includes but is not limited to, its coaches, assistant coaches, treasurers, managers, staff, affiliates, officers, officials, agents, assigns and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for activity (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, OR LOSS OR DAMAGE TO PERSON OR PROPERTY, regarding my child and/or arising from his/her activities, WHETHER ARISING FROM NEGLIGENCE OF THE RELEASEES, RELEASORS OR OTHERWISE, except for malicious misconduct, to the fullest extent of the law.
I hereby certify that the above-mentioned participant is in good health and fully able to participate in all activities of the ____________________and ___________________. By signing below, I am stating that I am also aware of and accept the risk inherent in the program activity. By signing below, I agree as well to hold harmless and indemnify __________________ and __________________, its affiliates, officers, agents, assigns and employees, from any and all liability, loss, damages, costs, refunds or expenses which are sustained, incurred or required out of the actions of my dependent in the course of any associated participation in the program.
Dated: _________________________ Parent or Guardian: ___________________________________________________
AGREEMENT TO ARBITRATE DISPUTES
IN THE EVENT OF ANY DISPUTE PERTAINING TO ANY PROVISION OF THIS AGREEMENT, OR PERTAINING TO THE SERVICES RENDERED PURSUANT TO THIS AGREEMENT, OR IN ANY WAY RELATED TO PARTICIPATION IN THIS PROGRAM, INCLUDING ANY CLAIM FOR PERSONAL INJURY OR ANY OTHER LOSS. THIS AGREEMENT INCLUDES, BUT IS NOT LIMITED TO ANY CLAIM AGAINST __________________________________________, COACHES, ASSISTANT COACHES, MANAGERS, TREASURERS, DIRECTORS, AGENTS, ASSIGNS OR EMPLOYEES OF THE CLUB, TEAMS, PROGRAMS OR OF ANY FOREGOING ENTITY. EACH PARTY HERETO AGREES TO SUBMIT TO BINDING ARBITRATION TO RESOLVE SUCH DISPUTES, BY CLAIM FILED, BEFORE A MUTUALLY AGREEABLE ARBITRATOR, CHOSEN BY THE PARTIES, WITH VENUE TO BE SAN JOAQUIN COUNTY, CALIFORNIA. IT IS FURTHER AGREED THAT ARBITRATION SHALL PROCEED UNDER THOSE RULES AND PROCEDURES SET FORTH BY JAMS, OR THOSE AGREED TO BETWEEN THE PARTIES.
In the event either party to this agreement incurs any expense as a result of the other party’s failure to comply with any provision of this agreement, the non-complying party shall be liable for reimbursement of any and all such expenses or attorney fees directly or indirectly related to failure to comply. In the event any legal action or proceeding occurs which is in any manner related to or pertaining to this agreement, attempting to challenge in a non-arbitral forum, such as a court of law, the validity or application of this agreement, the party who substantially prevails in that court or non-arbitral proceeding shall be entitled to receive reasonable costs of such action or proceeding including attorney’s fees. In the arbitration itself, each party shall bear its own attorneys’ fees. The following disclosures are intended to help you thoroughly understand the significance of agreeing to arbitrate any controversy, or claim, or issue in any controversy or claim which may arise between the undersigned client and the attorney:
1) ARBITRATION SHALL BE FINAL AND BINDING ON THE PARTIES.
2) THE PARTIES HERETO ARE WAIVING THEIR RIGHT TO SEEK REMEDIES IN COURT, INCLUDING THE RIGHT TO JURY TRIAL.
3) PRE-ARBITRATION DISCOVERY IS GENERALLY MORE LIMITED THAN AND DIFFERENT FROM COURT PROCEEDINGS.
4) THE ARBITRATOR’S (S)AWARD IS NOT REQUIRED TO INCLUDE FACTUAL FINDINGS OR LEGAL REASONING AND ANY PARTY’S RIGHT TO APPEAL OR TO SEEK MODIFICATION OF RULINGS BY THE ARBITRATOR (S) IS STRICTLY PROHIBITED.
E) THE ARBITRATOR OR PANEL OF ARBITRATORS WILL TYPICALLY INCLUDE AN ATTORNEY OR JUDGE, ACTIVE OR RETIRED.
BY SIGNING BELOW, YOU ARE SIGNIFYING UNDERSTANDING AND ACCEPTANCE OF THE PROVISIONS OF THIS AGREEMENT.
Dated: _________________________ Parent or Guardian: ___________________________________________________
I HAVE READ THE RULES AND POLICIES OF _____________________. I FULLY UNDERSTAND THE DUTIES, OBLIGATIONS AND RIGHTS ASSOCIATED WITH MY CHILD’S (S) PARTICIPATION AND I HERBY AGREE TO ACT IN ACCORDANCE WITH THIS AGREEMENT.
I HAVE READ THIS HEALTH FORM AND RELATED CERTIFICATIONS, THE RELASE OF LIABILITY, WAIVER, INDEMNIFICATION, ASSUMPTION OF RISK AGREEMENT, AND AGREEMENT TO ARBITRATE DISPUTES. I FULLY UNDERSTAND THEIR TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Dated: _____________________ Parent or Guardian: _______________________________________