Issuu on Google+

FREE FOOTIE SOCCER SOCIETY – INFORMED CONSENT AGREEMENT Name: Parent/Guardian: Address: City: Postal Code: Phone No: Birthdate: DISCLAIMER CLAUSE Free Footie Soccer Society and its officers, directors, agents, contractors, employees, coaches/instructors, referees, volunteers, members and representatives (all hereafter collectively referred to as “Free Footie”), is not responsible for any participant’s death, injury, loss or damage of any kind sustained by any person while participating in any of the activities provided, organized or arranged by Free Footie and all such related activities (all hereafter collectively referred to as “Free Footie Activities”), except to the extent that such injury, loss or damage was caused by the negligence of Free Footie. DESCRIPTION OF ACTIVITIES The following Free Footie Activities that your child may participate in with Free Footie include, but are not limited to:  Participation in camps, clinics or coaching courses;  Participation in regular-season soccer games and practices;  Participation in the season-end soccer tournament;  Travel to and from the regular-season games and season-end tournament. ASSUMPTION OF RISK In consideration of my child’s participation in Free Footie Activities, I and my child acknowledge that we are aware of, appreciate and accept the inherent physical risks and the other possible RISKS, DANGERS, AND HAZARDS associated with being a participant, including the possible risk of severe or fatal injury to my child or others. These risks include but are not limited to:  All manner of injuries resulting in muscular injuries and soft tissue injuries including bruises, scrapes, cuts, etc.  All manner of injuries resulting from the failure of apparatus/equipment;  All manner of injuries resulting in dislocations, concussions, hematomas, whiplash, contusions, sprains, pulled or strained muscles, knee injuries, and broken bones;  Transmission of diseases in various ways and types from contact with other participants resulting in death, disease or other illnesses;  All manner of head, neck, spinal, facial, eye, nose and/or dental injuries;  All manner of injuries and/or death that may result from transportation to and from Free Footie Activities;  Heat stroke, sunstroke, heat cramps or hypothermia which may result from extreme changes in weather or temperatures suffered by my child while participating in Free Footie Activities;  Medical problems arising before, during or after participation in Free Footie Activities;  Allergic reaction to food, plants, chemical and animal or insect life;  That my child’s risk of injury increases as they become fatigued; Initials:__________ ACKNOWLEDGMENT OF RESPONSIBILITIES The parent/guardian and the participant understand and acknowledge the following: 1. TO FOLLOW all the instructions and rules given by those responsible for or in charge of Free Footie Activities while my child is a participant and participating in Free Footie Activities. 2. TO OBEY all the instructions and rules pertaining to Free Footie Activities. Initials:_________ CONDITION OF REGISTRATION The parent/guardian and the participant understand and acknowledge the following: 1. That participations in Free Footie Activities include physical contact and to the best of my/our knowledge the participant is in good health and able to participate in all Free Footie Activities; 2. That the participant will wear the shin pads provided by Free Footie; 3. Should the participant be injured during Free Footie Activities I/we give permission to Free Footie to arrange for emergency medical treatment. Initials:__________ I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THIS AGREEMENT, that I understand, appreciate and accept the risks associated with my child’s participation in Free Footie Activities. I consent for my child’s participation in Free Footie Activities. Initials:__________ DATE SIGNED: Name of Participant: Name of Parent/Guardian: Signature of Parent/Guardian: Name of Witness: Signature of Witness: 1. Participant/Parent/Guardian: The personal information requested on this form is collected, used and disclosed by Free Footie for the purpose of administering the Free Footie Activities and its programming offered by Free Footie. Questions concerning the collection, use or disclosure of this information should be directed to: Dana Adams at dadams@fieldlaw.com or 587-337-3118. 2.

The witness information is being collected to verify the validity of the person who is signing as a witness to this document.

E1942117.DOCX;1


Free Footie Informed Consent Form (for players)