Waivers

Waiver Forms will be available in the Fall of 2024.

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IMPORTANT
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1Head Injury Waiver

2Consent to Treatment of a Minor

3Release & Waiver of Liability

4Advertising

5Medical & Signature

Head Injury Waiver

A concussion is the immediate and temporary impairment of the brain to function normally following a direct hit to the head. Signs and symptoms usually occur soon after the injury but, in some cases, may be delayed.

Symptoms include the following:

“Pressure in head”
Nausea or vomiting
Neck pain
Balance problems or dizziness
Blurred, double, or fuzzy vision
Sensitivity to light or noise
Feeling sluggish or slowed down
Feeling foggy or groggy
Drowsiness
Change in sleep patterns
Amnesia
Don’t feel right”
Fatigue or low energy
Sadness
Nervousness or anxiety
Irritability
More emotional
Confusion
Concentration or memory problems
Repeating the same question/comment
Headaches

Signs observed by teammates, parents and coaches include:

Appears dazed
Vacant facial expression
Confused about assignment
Forgets plays
Is unsure of game, score, or opponent
Moves clumsily or displays incoordination
Answers questions slowly
Slurred speech
Shows behavior or personality changes
Can’t recall events prior to hit
Can’t recall events after hit
Seizures or convulsions
Any change in typical behavior or personality
Loses consciousness

If any of the following symptoms intensify or begin after your athlete is released to you, call 911 immediately:

Bleeding from the nose and ears
Paralysis or marked weakness of limbs and facial muscles
Drainage of fluids from nose or ears
Loss of consciousness
Nausea and vomiting

What can happen if you keep on playing with a concussion or return to soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately. 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. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.

Confirm and acknowledge Head Injury Waiver *

I have read and fully understood the contents of the "Head Injury Waiver" form.

I hereby confirm that I have read and fully understood the contents of the waiver form titled Head Injury Waiver. I acknowledge that I am bound by the terms outlined therein and am aware of my rights, obligations, and responsibilities as stipulated in the contract.

Consent to Treatment of a Minor

The parent(s)/person on this signatured document having legal custody/legal guardianship of the student athlete on this documennt, do hereby authorize the athletic traininers at practice(s) and the game(s) to provide the below treatment.

These services are being provided by Cleats Vs Cancer in conjunction with the “Cleats Vs Cancer” Senior Football All-star game.

It is understood that this authorization is given in advance of any specific diagnosis or treatment being required but is given to provide authority to the below described agent(s) to give specific consent to any and all such diagnosis and treatment, meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable.

This authorization shall remain effective for one (1) year of signature, unless sooner revoked in writing by the parent and/or guardian, delivered to Cleats Vs Cancer agents.

Confirm and acknowledge Consent to Treatment of a Minor Waiver *

I have read and fully understood the contents of the "Consent to Treatment of a Minor" form.

Individual Statement of Understanding, Release and Waiver of Liability

In consideration of the acceptance of participation in the ‘Cleats vs Cancer’ Senior Football All-star game, by execution of the Player Information/Vendor Entry Form, I/We hereby release ‘Cleats vs Cancer’ Senior Football All-star game and all volunteers and officers and anyone connected with this event of any and all known and unknown damages, injuries, losses, judgements, and/or claim from any causes whatsoever that may be suffered by anyone participating in this event and/or by spectators at the event.

Confirm and acknowledge Individual Statement of Understanding Waiver *

I have read and fully understood the contents of the "Individual Statement of Understanding" form.

I hereby confirm that I have read and fully understood the contents of the waiver form titled "Individual Statement of Understanding, Release and Waiver of Liability." I acknowledge that I am bound by the terms outlined therein and am aware of my rights, obligations, and responsibilities as stipulated in the contract.

Advertising

In consideration of this event the family members, honorees, event performers and event spectators agree to permit the organizers of the ‘Cleats vs Cancer’ Football All-star game and its affiliates use of their name, all photos and video footage taken including voice recordings at the event for publicity, advertising and commercial purposes (including: newspapers, magazines, video, internet, radio and television) before, during and after the event and do hereby relinquish any rights whatsoever to any photos or video footage taken in conjunction with the event and give permission to publish or to sale or otherwise dispose of said photos solely to the ‘Cleats vs Cancer’ Football All-star game and its affiliates. All advertising and publicity rights reserved to the ‘Cleats vs Cancer’ Senior Football All-star game.

Confirm and acknowledge Advertising Waiver *

I have read and fully understood the contents of the "Advertising" form.

I hereby confirm that I have read and fully understood the contents of the waiver form titled "Advertising." I acknowledge that I am bound by the terms outlined therein and am aware of my rights, obligations, and responsibilities as stipulated in the contract.

Student's Legal Name *

First

Last

Students Birthdate *

Student's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent or Legal Guardian *

First

Last

Grade *

Student's Email Address *

Parent's Email Address *

Emergency Contact Phone #1 *

Student's Phone

Parent's Phone

Emergency Contact Phone #2 *

Medical & Insurance Information

Insurance Provider & Policy # (copy) *

Family physician & Phone # *

Insured Employer *

Existing medical conditions *

(i.e. medications, allergies, bee stings, etc.)

Are you aware of any health problems? *

Yes
No
Don't know

Is athlete currently under medical care? *

Yes
No
Don't know

Does the athlete have a history of a concussion (getting knocked out)? *

Yes
No
Don't know

Does athlete have asthma (wheezing), hay fever or coughing spells after exercise? *

Yes
No
Don't know

Has it ever been necessary to restrict athlete’s activities for medical reasons? *

Yes
No
Don't know

Has the athlete ever had any surgeries? *

Yes
No
Don't know

Does the athlete take any medication? *

Yes
No
Don't know

Does the athlete have any problems with vision (eyes)? *

Yes
No
Don't know

Has the athlete ever suffered a heart related illness (heat stroke)? *

Yes
No
Don't know

Has the athlete ever broken a bone, had to wear a cast or had an injury to any joint? *

Yes
No
Don't know

Does athlete require special care for any reason? *

Yes
No
Don't know

Is the athlete diabetic? *

Yes
No
Don't know

Explain any YES answers below:

Signature

Please confirm by checking the box below. *

I acknowledge that I have read and fully understood the contents of all five waiver forms.

I hereby confirm that I have read and fully understood the contents of all five waiver forms. I acknowledge that I am bound by the terms outlined therein and am aware of my rights, obligations, and responsibilities as stipulated in the contract.

Student's Signature *

Clear Signature

Parent or Legal Guardian's Signature *