2014/15 G-FORCE WINTER PROGRAM REGISTRATION FORM Please read + sign Liability Waiver on back of this form.

Transcription

1 2014/15 G-FORCE WINTER PROGRAM REGISTRATION FORM Please read + sign Liability Waiver on back of this form. PARTICIPANT INFO First Name: Last Name: DOB: c M c F Cell Phone: Mailing Address: City: State: Zip: Do you have any previous sliding sport experience? (previous experience not required) c YES c NO WINTER PUBLIC PROGRAMS Please select all programs that apply G-Force Bobsled Fantasy Camp $600 c Session #1: January 3, 2015 c Session #2: February 14, 2015 G-Force Skeleton Fantasy Camp $600 c Session #1: January 3, 2015 c Session #2: February 14, 2015 c G-Force Skeleton Experience $150 EMERGENCY CONTACT INFO Contact Name: Cell Phone: Other Phone: Relationship to Participant: 2 Ways to Return Form: to reservations@utaholympiclegacy.com In Person at UOP Reservations Desk (3419 Olympic Parkway, Park City UT) For Guest Services Administrative Use Only GS Rep: Date: Updated in POS: Enrollment #: c Waiver Signed Please read + sign Liability Waiver on back of this form.

2 RELEASE OF LIABILITY, ACKNOWLEDGMENT OF RISKS, AND CONSENT AGREEMENT THIS IS A LEGALLY BINDING AGREEMENT! PLEASE READ CAREFULLY BEFORE SIGNING! For and in consideration of the right to use and/or participate in any activity in any capacity at the Utah Olympic Park and/or any part of its facilities, including, but not limited to bobsledding, luge, skeleton, guided tours, Ziplines, Alpine Slide, aerial bungee, adventure courses, nordic skiing, and/or ski jumping of any kind (on snow or into water), I expressly agree, in addition to paying any fees due for any such activity(ies), to ASSUME ANY and ALL risks of injury, including the risk of serious injury and even DEATH, regardless of the cause of injury, the activity, or the date on which the injury is allegedly sustained. I acknowledge and understand that obeying and following safety rules and/or instruction does NOT guarantee my safety. The UOP is NOT in any manner an insurer of my safety. I further agree to FOREVER RELEASE the Utah Athletic Foundation d/b/a the Utah Olympic Legacy Foundation, the Utah Olympic Park, and its affiliates, related entities, employees, officers, directors, and agents (collectively referred to as the UOP ) from ANY and ALL LIABILITY, and to FOREVER WAIVE ANY and ALL claims, causes of action, charges, damages, and demands of any kind whatsoever, including for injuries I sustain as a result of UOP s NEGLIGENCE. I also expressly agree to accept AS IS and WITH ALL FAULTS any equipment that I use at the UOP and further understand and acknowledge that the UOP provides NO implied warranty of merchantability and/or fitness or any other warranties of any kind whatsoever and further agree that any activity I participate in at the UOP concerns services being rendered only. I hereby consent to allow the UOP to administer first aid and other emergency medical treatment to me for any injury or illness that occurs while at the UOP. I also grant to the UOP and its assigns the right to use, reproduce, display, distribute and make derivative works, in any and all media, of any biographical information furnished by me to the UOP and/or of my voice, image and/or likeness recorded while doing anything at the UOP. I have read and understand this Agreement and voluntarily enter into it without any reservation whatsoever and agree that all activities at the UOP are purely voluntary in nature. I further agree that no representations have been made to me other than those expressly contained herein. In the event any part of this Agreement is deemed unenforceable, the other portions will remain enforceable. In the event federal subject matter jurisdiction exists, I agree that any lawsuit concerning this Agreement and/or the UOP will be filed in the United States District Court for the District of Utah. This Agreement and its terms are perpetual, do not expire and apply to each and every day (today and in the future) that I use and/or participate in any activity at the Utah Olympic Park and/or any part of its facilities even if such days are not consecutive. Dated this day of, 201. Signature of Adult Particiapnt Print First and Last Name of Adult Participant On behalf of my minor child(ren), I hereby agree that all the same risks and consents noted above apply to my child(ren) as well and acknowledge that the above risks exist, that the UOP is not a guarantor of my child(ren) s safety and if I do not wish to accept these terms, I should not allow my child(ren) to participate in any activity at the UOP. My child(ren) s name(s) is/are (PRINT):. My signature applies here. CONTACT INFORMATION Program Name: Date of Birth:: / / Mailing Address: City: State: Zip: Home Phone: Cell Phone: Emergency Contact: Emergency Contact Phone Number: FY15

3 UTAH OLYMPIC PARK CONCUSSION ANNUAL CONSENT FORM I, of Sport Program Athlete Name Sport Program Name Herby acknowledge having read and understand education on the signs, symptoms, and risks of sport related concussion and policy/protocol of return to sport. I also acknowledge my responsibility to report to my coaches, parent (s)/guardian (s) any signs or symptoms of concussion. Signature of athlete or Parent if athlete is a minor Date I, the parent/guardian of the athlete named above, hereby acknowledge having received and familiarized myself with the following: 1) Utah Olympic Park s Concussion Management Protocol for: (please check your child s program) FLY Freestyle Park City Nordic Ski Club G- Force Bobsled/Skeleton Explorers 2) CDC s Concussion in Sport: Printed name of parent/guardian Date For current information on signs, symptoms and prevention of concussions, please visit: Parent Consent Form 2014/2015

4 Concussion Management Protocol for G- Force Program Baseline ImPACT testing Recommended but not mandatory - Can be done anytime but ideally recommended before season begins - Ideally this should be done annually especially for young athletes under age 13 - If no individual Baseline test completed, should injury occur, athlete WILL BE required to be cleared with medical/clinical evaluation and impact testing utilizing age/gender normative data ANY Suspected Head Injury No Return to Sport that Day Action Plan Activated ACUTE ACTION PLAN REMOVE athlete from sport, observe for signs/symptoms Immediate Medical Triage EMS and Referral to Medical Facility if indicated Record time of initial incident and Mechanism of injury communicate to medical personnel if being transported or to parents these details and the following if observed: a. Any Loss of Consciousness b. Memory Loss before or after the incident c. Any seizures If not transported, athlete should observed by coach or responsible party until parents arrive NOTIFY PARENTS Parents given home care instructions (CDC ACE Form/thinkheadfirst.com) and advised to contact Think Head First for any questions regarding post injury follow up Coach informs Club Administration of incident Further Action: Athlete monitored over hrs by responsible individual for worsening symptoms or delayed responses. Any worsening of symptoms or if any of the 3 details listed above were observed, then transport à Medical facility to be evaluated clinically with any additional testing as deemed necessary. If no problems and symptoms improving or resolved, schedule follow up evaluation within hours to include: Medical evaluation, symptom survey, balance assessment ImPACT post injury evaluation if symptom appropriate Post Injury ImPACT Assessment: If the Medical Personnel clears athlete medically and athlete essentially symptom free, then the post injury ImPACT screen can be completed. Think Head First CIC notified to arrange ImPACT post injury evaluation. This testing is possible to accomplish online from anywhere with an internet connection. Instructions will be given on how to access the post injury testing if out of Park City. 3. Once test completed, Think Head First CIC will review ImPACT result and will subsequently advise athlete, parent, coach and trainer regarding status for Return to Sport Progression.

5 Return to Sport Progression Basic Requirements Necessary to BEGIN Return to Sport Progression: 3. Asymptomatic at Rest Athlete symptoms have resolved at rest Normal medical exam Normal medical/clinics screen and balance evaluation ImPACT Normal post injury ImPACT return to baseline levels or acceptable compared to normative data General Return to Sport Guidelines: - The following represents a generalized progression in activities that can be scheduled once the athlete is symptom free at rest. Generally, 1 or more levels can be completed daily before progressing to the next level. Ideally, the initial RTS Conditioning Steps will be monitored by a Therapist or Athletic Trainer. - If ANY signs/symptoms return with any level of activity, stop and rest until symptoms clear and then begin at level where symptoms occurred. Initial Recovery Conditioning Progression: Activities of Daily Living rest with light walking around home, short bouts of cognitive challenges (homework, reading, computer) etc. Possibly light manual massage, vestibular therapy if indicated Supervised: Light Cognitive activity reading, limited school work or computer work (short duration/15-20 mins with plenty of recovery between work intervals. Low levels of physical activity such as hike/walk, stationary bike, etc for mins with no return of symptoms progress to jogging if hike/walk ok. Stretching/light yoga, balance drills, light strength exercises. 3. Supervised: Increasing cognitive stressors (more in school and increased homework loads). Increased cardio stressors to moderate, increased volume and some interval type. Increased strength challenges, balance challenges and sport specific drills. 4. Supervised: School full time. Resume full aggressive training without contact and management of risks. Cardio interval training, Strength full training loads, Impact/Agility at full sport loads, Balance training with no deficits. 5. Supervised by coach in program Sport Specific return to sport training progressions. Sport Specific - Return to Sport Guidelines: Dry- land Conditioning à Progression Into On Ice Training à Competition: SKELETON ATHLETES & BOBSLED DRIVERS Supervised light warm- up at moderate speeds with emphasis on stretching, flexibility, light plyometrics and limited core work. Supervised full warm- up, - 1/2 load of physical training activities including sprinting, weight training & plyometrics. 3. Supervised full warm- up, - 3/4 load of physical training activities including sprinting, weight training & plyometrics. 4. Return to full load physical training. 5. One run as passenger or brakeman in a bobsled from Bobsled Start with qualified driver. No push start. 6. One run as a driver from Junior Start. 7. Two runs as a driver from Junior Start 8. Two runs starting between curve 2 & curve Two runs from Bobsled/Skeleton start with no push start. 10. Two runs from Bobsled/Skeleton start with full push start

6 1 Return to full training load. 1 Return to full competition. Athlete must be approved by head coach to enter into competition based on return to full training evaluation. Sport Specific - Return to Sport Guidelines: BOBSLED PUSH ATHLETES Supervised light warm- up at moderate speeds with emphasis on stretching, flexibility, light plyometrics and limited core work. Supervised full warm- up, - 1/2 load of physical training activities including sprinting, weight training & plyometrics. 3. Supervised full warm- up, - 3/4 load of physical training activities including sprinting, weight training & plyometrics. 4. Return to full load physical training. 5. One run as passenger or brakeman in a bobsled from Bobsled Start with qualified driver. No push start. 6. One run with push from Bobsled Start. 7. Two runs with push from Bobsled Start. 8. Return to full training load. 9. Return to full competition. Athlete must be approved by head coach to enter into competition based on return to full training evaluation.