434 Sportsplex Facility Waiver



Player Name *
Player Name
Date of Birth *
Date of Birth
Name of Parent/Guardian Name *
Name of Parent/Guardian Name
Address *
Concussion Procedure and Protocol for US Youth Soccer *
Concussion: a traumatic brain injury that interferes with normal brain function. Medical, a concussion is a complex, pathophysiological even to the brain that is induced by trauma which may or may not involve a loss of consciousness (LOC). Concussion results in a constellation of physical, cognitive, emotional, and sleep-related symptoms. Signs or symptoms may last from several minutes to days, weeks, months or even longer in some cases. CONCUSIION SIGNS, SYMPTONS, AND MANAGEMENT AT TRAINING AND COMPETITIONS Step 1: Did a concussion occur? Evaluate the player and note if any of the following signs and/or symptoms are present: 1. Dazed look or confusion about what happened. 2. Memory difficulties. 3. Neck pain, headaches, nausea, vomiting, double vision, blurriness, ringing noise or sensitive to sounds. 4. Short attention span. Can’t keep focused. 5. Slow reaction time, slurred speech, bodily movements are lagging, fatigue, and slowly answers questions or has difficulty answering questions. 6. Abnormal physical and/or mental behavior. 7. Coordination skills are behind, ex: balancing, dizziness, clumsiness, reaction time. Step 2: Is emergency treatment needed? This would include the following scenarios: 1. Spine or neck injury or pain. 2. Behavior patterns change, unable to recognize people/places, less responsive than usual. 3. Loss of consciousness. 4. Headaches that worsen. 5. Seizures. 6. Very drowsy, can’t be awakened. 7. Repeated vomiting. 8. Increasing confusion or irritability. 9. Weakness, numbness in arms and legs. Step 3: If a possible concussion occurred, but no emergency treatment is needed, what should be done now? Focus on these areas every 5-10 min for the next 1-2 hours, without returning to any activities: 1. Balance, movement. 2. Speech. 3. Memory, instructions, and responses. 4. Attention on topics, details, confusion, ability to concentrate. 5. State of consciousness. 6. Mood, behavior, and personality. 7. Headache or “pressure” in head. 8. Nausea or vomiting. 9. Sensitivity to light and noise. Step 4: A player diagnosed with a possible concussion may return to US Youth Soccer play only after release from a medical doctor or doctor of osteopathy specializing in concussion treatment and management. Step 5: If there is a possibility of a concussion, do the following: 1. The attached Concussion Notification Form is to be filled out in duplicate and signed by team official of the player’s team. 2. If the player is able to do so, have the player sign and date the Form. If the player is not able to sign, note on player’s signature line “unavailable”. 3. If a parent/legal guardian of the player is present, have the parent/legal guardian sign and date the Form, and give the parent/legal guardian one of the copies of the completed Form. If the parent/legal guardian is not present, then the team official is responsible for notifying the parent/legal guardian ASAP by phone or email and then submitting the Form to the parent/legal guardian by email or mail. When the parent/legal guardian is not resent the team offical must make a record of how and when the parent/legal guardian was notified. The notification will include a request for the parent/legal guardian to provide confirmation and completion of the Concussion Notification Form whether in writing or electronically. 4. Player Pass a. In league play. The team official must also obtain the player’s pass from the referee, and attach it to the copy of the Form retained by the team. b. In tournament play, including, but not limited to, Regional and National Tournament play in the US Youth Soccer National Championships and President’s Cup. The tournament committee will obtain player’s pass and keep it until a proper medical release relating to the injured player is received by the committee. References: Kissick MD, James and Karen M. Johnston MD, PhD. “Return to Play After Concussion.” Collegiate Sports Medical Foundation. Volume 15, Number 6, November 2005. http://csmfoundation.org/Kissick_-_return_to_play_after_concussion_-_CISM_2005.pdf April 22, 2011 National Federation of State High School Associations. “Suggested Guidelines for Management of Concussion in Sports” – 2008 NFHS Sports Medicine Handbook (Third Edition). 2008 77-82 http://www.nfhs.org April 21, 2011
Assumption of Risk - Waiver of Liability - Indemnfication Agreement *
434 Sportsplex Corp, Chris Riley Footskills, LLC d/b/a Riley Development Academy and CR Land, LLC Assumption of Risk – Waiver of Liability – Indemnification Agreement The activities of Chris Riley Footskills, LLC d/b/a Riley Development Academy (RDA) and Chris Riley, individually (collectively hereafter referred to as RDA) and CR Land, LLC and 434 Sportsplex Corp, /include soccer and fitness training/activates. They offer the participant, fun, competition, and wholesome recreation. Benefits include getting away from the TV, physical activity, and healthful social interaction, as well as the potential to improve one’s soccer skill and ability. The required physical exertion is suitable for most levels of fitness and skill. While the many benefits of these activities are apparent, RDA and CR Land, LLC and 434 Sportsplex Corp. and its staff regard participation safety as a top priority and feel it is important that the participant (and parent/guardian) understand that there are risks inherent in the activity regardless of the care taken by RDA and CR Land, LLC and 434 Sportsplex Corp. Some risks that are inherent in the activity and cannot be totally eliminated include tripping, slipping and falling, and collisions. Other inherent risks include, but are not limited to unexpected equipment failure, errors in judgement bye RDA and CR Land, LLC and 434 Sportsplex Corp. employees, and physical injury while playing soccer. RDA and CR Land, LLC and 434 Sportsplex Corp. feels that it is important that the participant (and parent/guardian) understand that three types of injuries can occur. Minor injuries are the most common and include, but are not limited to, muscle soreness, headaches, and bruises. Serious injuries are less common, but do occur occasionally. They include, but are not limited, to strained/torn muscles, broken bones and internal injuries. WHAT IS THE THIRD? Assumption of Inherent Risks: I, the ADULT PARTICIPANT [OR MINOR PARTICIPANT AND PARENT(S) OR GURDIAN(S), (hereafter referred to as PARTICIPANT/PARENT) understand that all activates of RDA and CR Land, LLC and 434 Sportsplex Corp. Include inherent risks that cannot be totally eliminated regardless of the care taken by RDA and CR Land, LLC and 434 Sportsplex., PARTICIPANT/PARENT 1) know, 2) understand, and 3) appreciate the types of injuries inherent in RDA activates, PARTICPANT/PARENT hereby asserts that PARTICIPANT/PARENT knowingly assume all inherent risk of activity. Waiver of Liability for Ordinary Negligence of RDA and CR Land, LLC and 434 Sportsplex Corp.: In consideration of permission to participant in and use the property, facilities, equipment, and services of RDA and CR Land, LLC and 434 Sportsplex Corp., today and all future dates, PARTICIPANT/PARENT, on behalf or [myself, my spouse, heirs, personal representatives, and assigns = Releasing Parties] do hereby waiver, release, discharge and covenant not to sue RDA and CR Land, LLC and 434 Sportsplex Corp. [including, owners, directors, officers, employees, volunteers, independent contractors, agents and equipment suppliers = Protected Parties] from liability from any and all claims arising from the ordinary negligence of Protected Parties. This agreement applies to 1) personal injury (including death) from incidents or illnesses arising from participation in RDA and CR Land, LLC and 434 Sportsplex Corp. activities including, but not limited to: [recreational, practices, or competitive activity; events; organized or individual training or conditioning activities; tests, classes, and instruction; observers or spectators; individual use of facilities, equipment, shower/locker room areas, and all premises including the associated sidewalks and parking lots and to 2) any and all claims resulting from the damage to, or theft of property = Inclusive Activities. Indemnification: PARTICIPANT/PARENT also agree to hold harmless, defend, and indemnify RDA (that is, defend and pay any judgement and costs, including investigation costs, attorney’s fees, and related expenses) from any and all claims or Releasing Parties arising from participation in Inclusive Activities, (including those arising from the inherent risks of the activity or the ordinary negligence of Protected Parties). PARTICIPANT/PARENT further agree to hold harmless, defend, and indemnify RDA and CR Land, LLC, and 434 Sportsplex Corp. against any and all claims of co-participants, rescuers, and others arising from the conduct of the participant in Inclusive Activities. Clarifying Clause: PARTICIPANT/PARENT confirm that 1) this agreement supersedes any and all previous oral or written promise or agreements. I understand that this is the entire agreement between me and RDA and CR Land, LLC and 434 Sportsplex Corp. and cannot be modified or changed in any way by representations or statements by any agent or employee of RDA and CR Land, LLC and 434 Sportsplex Corp.; 2) the foregoing Assumption of Risk, Waiver or Liability, and Indemnification Agreement is intended to be as broad and inclusive as is permitted by laws of the State of New York and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect; and 3) if legal action is brought, the appropriate trail court is Supreme Court in the County of Broome and the State of New York has the sole exclusive jurisdiction and that only the substantive laws of the State of New York shall apply. Acknowledgment of Understanding: PARTICIPANT/PARENT have read and understood this Agreement. I understand that I am giving up substantial rights, including the right of the PARTICIPANT/PARENT to sue for damages in the event of death, injury or loss. I acknowledge that I am voluntarily signing the agreement, and intend my signature to be a complete release of all liability, including that due to ordinary negligence by the Protected Parties, to the greatest allowed by law of the State of New York. I further acknowledge that I have been made aware of Riley Development Academy’s concussion procedure and protocol, which follows that of US Youth Soccer, either by receiving a copy or it being available on the website. I further acknowledge that in the event my child has any special medication needs or conditions which is they should occur may result in life threatening situation for my child, that I will promptly advise RDA and CR Land, LLC and 434 Sportsplex.
Name of Parent/Guardian or Player if over 18 *
Name of Parent/Guardian or Player if over 18