CONSENT TO PARTICIPATE IN SCHOOL-SPONSORED SPORTS

Transcription

1 CONSENT TO PARTICIPATE IN SCHOOL-SPONSORED SPORTS THIS FORM CONTAINS THE CONDITIONS UNDER WHICH YOUR CHILD MAY PARTICIPATE IN THE STRATFORD SCHOOL SPORTS PROGRAM(S). PLEASE ENSURE YOU READ IT CAREFULLY BEFORE SIGNING AND THAT YOU DIRECT ANY QUESTIONS TO YOUR PRINCIPAL. By signing below, I authorize my child,, to participate in (the Sport ) through Stratford School. I understand that in authorizing my child to participate in the Sport, I am agreeing to the following: 1. My child will not be permitted to participate in the Sport unless and until I have submitted all of the following (fully completed) to Stratford School. a. Emergency Medical Treatment/Confirmation of Insurance form b. Certification of Health from student s doctor (examination must have been within 90 days prior to start of the Sport) 2. I understand that participation in the Sport is completely voluntary, and not a condition of enrollment or maintaining good standing as a student at Stratford School. 3. I am familiar with the Sport in which my child will be participating. I know that there are risks associated with the Sport, and that injury or illness as a result of participating in the Sport is possible and is unpredictable. Injuries can range from small scrapes, bumps, and bruises, to more serious injuries requiring immediate medical attention. Injuries can occur at any time, including while getting ready to play, while warming up, while practicing, while playing, while watching, or while on the way to or on the return from a game, match, or meet. I also understand that although there will be at least one person over the age of 18 acting in the capacity as a coach to assist participants in learning and improving their skills in the Sport, the coach cannot control the behavior of all the participants all the time. Further, I understand that neither Stratford School, nor any coaches, is responsible for the behavior of my child. I, on behalf of my child, assume all responsibilities and all risks associated with my child s participation in the Sport, including all risks of injury or illness. As a condition of my child participating in the Sport, I hereby fully release and discharge Stratford School (and any of its employees, officers, directors, investors, insurers, agents, representatives, attorneys, and volunteers) Rev. 8/13/13:ENR - 1 -

2 from any and all liability arising out of or relating to my child s participation in the Sport, including, but not limited to, liability for any injury, regardless of severity, arising from or resulting from my child s participation in the Sport. 4. I understand that my child is responsible for behaving in a respectful and appropriate manner at all times in connection with his/her participation in the Sport. My child is expected to behave respectfully and in accordance with all rules, standards, and expectations of Stratford School and the coach(es) towards all game officials, opposing players, teammates, coaches (including his/her own as well as opposing coaches), fans of all teams, and others. My child is subject to being disciplined for any behavior which, in the sole discretion of Stratford School or the coach(es) is deemed inappropriate, disruptive, unsafe, or otherwise unacceptable. The discipline may include, but not be limited to, temporary suspension from playing in one or more games or portions thereof, expulsion from the team, or other sanctions, and could, in some instances, lead to suspension or expulsion from Stratford School. 5. I represent that my child is in good health and has no known medical (physical or mental) conditions or illnesses that would prevent my child from participating fully in the Sport. I acknowledge and understand that if my child is currently taking medications for any reason, neither Stratford School, nor any of its employees, coaches, or volunteers have any obligation or responsibility to administer such medication to my child, to keep or maintain such medication for my child, or to remind my child to take such medication at any time. Such responsibility at all times remains the exclusive responsibility and obligation of me and my child. 6. I understand that in cases where Stratford School provides transportation with a school van and a driver employed by Stratford School, that I hereby agree, both on behalf individually as a parent and on behalf of my child, to waive, release, indemnify and hold harmless Stratford School, its agents, officers, directors, investors, insurers, representatives, attorneys, volunteers, and employees to the extent allowed by law from and against any and all injuries or damages which I or my child may suffer for any claims of negligence or alleged negligent act(s) or omission(s) arising out of or in any way connected with my child s travel or participation in the Sports program. I acknowledge that the Sports Van Transportation Service is available as a convenience for parents, and fully assume the risks associated with participation in the service. I also understand that it is my responsibility to satisfy myself concerning any safety or other questions I might have. I have read this paragraph and understand and agree that this is a Release and Waiver of claims both on behalf of myself and my child and that I am relinquishing rights by signing this agreement and have done so voluntarily. Any dispute between the parties arising out of this agreement shall be submitted to final, binding arbitration before a retired judge and conducted in Santa Clara County under the Comprehensive Rules of Arbitration by JAMS in effect at the time arbitration is demanded. The arbitrator shall be selected by mutual agreement, or of that is not possible, pursuant to the Comprehensive Rules of JAMS governing selection of arbitrators. Each party shall bear their own costs, attorneys fees, and expenses of the Rev. 8/3/15:ENR - 2 -

3 arbitration and an equal share of the arbitrator s fees. Any arbitration shall be subject to the same statutes of limitations as would apply in the absence of an arbitration provision. THE PARTIES IRREVOBCABLY WAIVE THE RIGHT TO A COURT OR JURY TRIAL. 7. I understand that in cases where Stratford School does not provide transportation to/from practice gyms or fields, to/from games or meets, to/from any team meeting, or for any purpose related to the Sport, the transportation of my child is exclusively my responsibility and obligation. As a condition of my child participating in the Sport, I hereby fully release and discharge Stratford School (and any of its employees, officers, directors, investors, insurers, agents, representatives, attorneys, and volunteers) from any and all liability arising out of or relating to my child s transportation, including, but not limited to, liability for any injury, regardless of severity, arising from his/her transportation to or from practice, to or from games/meets, to or from Sport-related meetings, and to or from Sport-related team parties. 8. I understand nothing in this Consent can be changed unless it is in writing signed by me and Stratford School s Chief Operating Officer or Chief Academic Officer. I understand that each coach or team may have some additional rules, regulations, or code of conduct which my child (and I) must follow as a condition of participation in the Sport. If those additional rules, regulations or code of conduct conflicts with this Consent, the terms of this Consent will supersede those rules, regulations and code of conduct to the extent of such conflict. Date: Signature Print Name/Relationship to Child Rev. 8/3/15:ENR - 3 -

4 EMERGENCY MEDICAL TREATMENT/CONFIRMATION OF INSURANCE I hereby authorize Stratford School, and any of its employees or coaches, and any of its volunteers working with Stratford School s sports program ( Program ) to secure emergency medical treatment for my child,, as deemed necessary and appropriate. I understand that efforts will be made to reach me, or the designated emergency contact referenced below. Contact Information (All items must be completed in full): Student s Full Name: Birthdate: Gender: Father/Mother/Legal Guardian Name: Day Phone: Mobile: Evening: Emergency Contact (other than parent or legal guardian): Relationship to student: Day Phone: Mobile: Evening: Student s primary doctor: Name: Phone: Preferred Hospital: Allergies: Current Medications (include name, dosage, frequency). It is extremely important to keep this information updated at all times. Rev. 7/26/12:ENR

5 I certify that my child,, has, and will have at all times while participating in (the Sport ) through Stratford School, medical insurance coverage for any illnesses or injuries he/she may incur. I understand and agree that I must maintain appropriate medical insurance coverage for my child as a condition of my child s participation in the Sport. I certify that the following information is accurate concerning my child s insurance coverage, and that I will inform Stratford School immediately in writing of any change in any of my child s medical insurance information. I also acknowledge and understand that Stratford School at no time provides or will provide medical insurance coverage for my child while participating in the Sport. Primary Insurer: Name of Insurer: Group # or Policy#: Phone # for Claims: Phone # for Authorization: Name of Subscriber: Subscriber ID#: Secondary Insurer (if any): Name of Insurer: Group # or Policy#: Phone # for Claims: Phone # for Authorization: Name of Subscriber: Subscriber ID#: I certify that all information contained in this two-page form is accurate and complete. I understand that I must update any information that changes while my child is participating in the Sport as soon as possible. If any information changes that may render my child unable to participate in the Sport (either because it is a condition imposed by Stratford School, or for any other reason), I agree immediately to inform Stratford School. Date: Signature Print Name Relationship to Student: Rev. 7/26/12:ENR

6 CERTIFICATE OF HEALTH I am a medical doctor licensed to practice medicine in California. I hereby certify that ( Student ) was examined by me on, 20 and found to be in good health. I understand the Student seeks to participate in (the Sport ). Based on my medical examination of the Student and the Student s medical history, there is no medical reason the Student cannot participate fully in the Sport. Date: Signature Print Name/Medical License # Name of Medical Group/Practice Name Address: Phone: Rev. 7/26/12:ENR