Waivers

Athlete Concussion Waiver

Reformatted from the Center for Disease Control’s “Heads Up for Concussion in Youth Sports Program”

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or a jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a “ding”, “getting your bell rung”, or what seems to be a mild bump or blow to the head can be serious.

What are the signs and symptoms of concussion?

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If an athlete reports one or more symptoms of concussion listed below after a bump, blow or jolt to the head or body, s/he must be kept out of play the of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom free and it’s OK to return to play.

Signs Observed by Coaching Staff

• Appears dazed or stunned
• Is confused about assignment
• Forgets an instruction
• Is unsure of game, score or opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows mood, behavior or personality changes
• Can’t recall events prior to hit or fall
• Can’t recall events after hit or fall

Symptoms Reported by Athletes

• Headaches or “pressure” in the head
• Nausea or vomiting
• Balance problems or dizziness
• Double or blurry vision
• Sensitivity to noise
• Feeling sluggish, hazy, foggy or groggy
• Concentration or memory problems
• Confusion
• Just not “feeling right” or “feeling down”

Concussion Danger Signs

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs.

• One pupil larger than the other
• Is drowsy or cannot be awakened
• A headache that not only does not diminish, but gets worse
• Weakness, numbness, or decreased coordination
• Repeated vomiting or nausea
• Slurred speech
• Convulsions or seizures
• Cannot recognize people or places
• Becomes increasingly confused, restless, or agitated
• Has unusual behavior
• Loses consciousness (even a brief loss of consciousness should be taken seriously).

Why should an athlete report their symptoms?

If an athlete has a concussion, his/her brain needs time to heal. While an athletes brain is still healing s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

What should you do if you think your athlete has a concussion?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom free and it’s OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a healthcare professional.

For further concussion information, go to http://www.cdc.gov/concussion/

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.

Waiver - Indemnity Agreement

The below-named Participant (“Participant”), and/or the Guardian identified above or below (“Guardian”) acting on behalf of such Participant as his legal guardian, as applicable, in exchange for the right of Participant to participate in all activities related to the Cleats Vs. Cancer football game, including all related practices, trainings and ceremonies (collectively, the “Activities”), and to also use all facilities, fields, equipment and related and surrounding areas related to or associated with the Activities, hereby agrees to indemnify, defend, protect and hold harmless CLEATS VS. CANCER, and all of its affiliates, directors, officers, members, managers, administrators, faculty, staff, employees, associates, volunteers, coaches, coordinators, agents and representative (collectively “CVC”) from and against and any and all claims, injuries, damages, losses, expenses, liabilities, suits or actions of any nature or kind whatsoever (collectively “Claims”), including Claims that may be brought by Participant, or by Guardian, or by the parents, spouses, relatives, family members or legal guardians of Participant or Guardian, arising from or connected in any way with the Activities, including the acts, omissions, negligence, misconduct or fault of any of the following in relation to the Activities: (1) Participant or of any of his representatives, parents, spouses, relative, guardians or family members; (2) CVC, or (3) of any other persons or participants (or their agents) during, arising from or in relation to the Activities, regardless of whether such Claims may arise (in whole or in part) from the alleged acts, omissions, negligence or fault of Participant or of CVC.

Participant/Guardian fully recognizes and understands that sports and recreation activities involve an element of risk of bodily injury, and hereby assumes and accept those risks and hazards which arise from and/or are incidental to such participation. In consideration of the opportunity for Participant to participate in the Activities, should such Activities cause or result in any harm, illness, injury (including death), casualty, loss, damage or expense of any nature to Participant, the undersigned Participant/Guardian (as applicable) hereby releases, absolves, and discharges, and also hereby agrees to indemnify, defend and hold harmless, CVC from any Claims or any nature arising out of or related in any way to the Activities, regardless of the cause of any such Claims, and hereby agrees to assume all such risk related thereto.

Participant/Guardian consents to the participation by the Participant in the named above in the Activities, and authorizes medical/dental care and treatment for Participant, as necessary, while under the supervision of any CVC representatives, coaches or similar volunteers, and agrees to be responsible for and pay for the costs of such treatment. Participant/Guardian further acknowledges and agrees that Participant is physically capable of participating in such activities, Participant/Guardian acknowledges having read the foregoing in all respects, and Participant/Guardian is executing this Agreement voluntarily and without coercion or duress, and hereby agree to all of the foregoing terms.

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.