I,(parent/guardian), hereby waive and release, indemnify, hold harmless and forever discharge Juventus Academy San Antonio, Juventus F.C., Soccer Central San Antonio, and any other partner or provider of facilities, its agents, employees, officers, directors, affiliates, successors and assigns are hereby jointly and severally referred to herein as Released Parties, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages, and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have arising from or in any way related to my participation.
I understand the activities that I will participate in can be dangerous and may cause serious or grievous injuries, including bodily injury and/or death. On behalf of myself, child, my heirs, assigns and next of kin, my child, my spouse (if applicable), and I waive all claims for damages, injuries, and death sustained that we may have against Released Parties regarding any such activity. I certify to the best of my knowledge that my current physical condition is satisfactory for participation in the Juventus Academy San Antonio program and that I am free of any health problems which would endanger my participation. I will inform the staff should my condition change at any time during my participation in this program. This waiver of liability does not apply to any acts of gross negligence or intentional, willful, or wanton misconduct.
Recognizing the possibility of injury or illness, and in consideration for Soccer Central and members of Soccer Central San Antonio accepting myself as a player in the soccer programs and activities of Soccer Central and its members (the “Programs”), I consent to participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify Soccer Central, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for the Programs, against any claim by or on my behalf as a result of my participation in the Programs and/or being transported to or from the Programs.
1. CONSENT FOR ROUTINE OR EMERGENCY CARE: I hereby authorize a Licensed Athletic Trainer (“LAT”) employed by the University of Texas Health Science Center at San Antonio (UTHSA) to evaluate and treat any injuries incurred by the player. Potential injuries could include but are not limited to, sprains, strains, fractures, abrasions, dislocations, concussions, and other athletic injuries. I understand that signing this permission form does not limit or modify my right to take the player/s to see a family physician or specialist and that I may do so at any time. By giving this permission, I understand that the LAT may be in direct contact with the player, that such contact may be prolonged in duration, occurring in proximity, and may require physical contact between the LAT and the player (i.e., hands-on, care-related activities). I understand the LAT may be involved in establishing a safe return plan for the player post-injury. I also give my permission to the LAT to inform school officials and medical provider of the player’s injury and changes in injury status as they occur.
During an emergency, the LAT may do what is needed to support the safety and health of the player. These actions may include treatment, activation of the Emergency Medical System (EMS), and contact with the parent/player’s legal representative. The LAT will consult the parent/player’s legal representative about any additional treatment the player may need.
2. ADDITIONAL INFORMATION
a) I understand that the player may participate in baseline and post-injury concussion neurocognitive testing.
b) I understand that the player must refrain from practice while injured and/or ill, whether receiving medical care or not. When under medical care, the player may not return to participation until given permission by a physician, physician’s delegate, or licensed athletic trainer. This may occur during or at the conclusion of medical treatment. The overseeing health care provider has the final authority regarding participation status following injury/illness.
c) I understand and agree that, as a player, if I experience an injury, illness, or change in health status it is my responsibility to inform the head coach and the licensed athletic trainer. Players must adhere to the established injury management guidelines, including rehabilitation and reassessment before being released to return to full participation.
d) I understand that at athletic trainer discretion, the player may be referred to additional healthcare providers for diagnosis and treatment of any injury and/or illness. It the responsibility of the parent/legal representatives to arrange for care.
e) I hereby authorize the VMH LAT to view and document in the electronic health record which includes protected health information directly related to the evaluation and treatment of a known or suspected injury sustained during athletic participation or for an injury and or illness that interferes with the ability to participate.
The undersigned certifies that the player and/or parent/legal representative has read this form, understands its content and significance, and is competent and authorized to execute it on the player’s behalf.