For and in consideration of being permitted to utilize the SOCCER SPORTSPLEX, INC. facility, the undersigned participant, or if the participant is under eighteen (18) years of age, the undersigned parent/guardian of the participant does hereby acknowledge and agree:
1. That participation in sports is hazardous and may result in injury or death:
2. That I assume and/or assume on behalf of my child or ward, all risk of injury, both known or unknown,
or loss incurred at or arising out of the use of or presence in SOCCER SPORTSPLEX, INC., or on its grounds.
3. I willingly agree to comply with the stated and customary terms and conditions for participation; if however I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and
4. That for myself and/or for my child or ward, our heirs, executors, administrators, and personal representatives, I do hereby:
a. forever waive, release and hold harmless SOCCER SPORTSPLEX, INC., its shareholders, directors, officers, agents, employees and owner of the facility from and against any and all claims, actions, demands, costs or expenses, including but not limited to negligence,
bodily injury, wrongful death, theft or property damage arising directly or indirectly out of participant’s use of or presence in SOCCER SPORTSPLEX, INC. or its grounds.
b. agree to indemnify and reimburse SOCCER SPORTSPLEX, INC., its shareholders, directors, officers, agent, and employees, and the owners of the facility for any losses, judgments, costs or
expenses, including legal fees, that may incur as a result of any claims, actions, or demands which may be brought, including but not limited to, negligence, bodily injury and/or loss, theft or destruction of personal property arising directly or indirectly out of participant’s use of or presence in SOCCER SPORTSPLEX, INC., or on its grounds.
5. Consent to contact emergency personnel in the event of injury. I, on behalf of myself and/or as the parent or guardian of any child or ward of mine utilizing the SOCCER SPORTSPLEX, INC. facility, authorize the emergency transportation of myself or my child / ward to a medical treatment facility in any situation where an employee of SOCCER SPORTSPLEX, INC. deems transportation to a medical treatment facility appropriate and where I am not able to make the decision to have myself or my child / ward transported to a medical treatment facility. This consent is intended to include, but it not limited to, transportation where I am unable due to lack of consciousness to consent to emergency transportation to a medical treatment facility and the emergency transportation of any minor or ward of mine in the event I am not physically present at the SOCCER SPORTSPLEX, INC. facility when the need for emergency transportation arises.
6. I understand that photographs of participants may be used for marketing or promotional purposes for the Soccer Sportsplex and hereby grant permission for my or my child’s photograph to appear in such promotional literature.
7. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Print Name of Participant Participant’s Date of Birth
Print Participant’s Address Print Participant’s City, State, and Zip Code
Print Name of Participant’s Team Participant’s Home Telephone Number
Participant’s E-mail Address
Signature of Participant or Parent/Guardian if under 18 yrs. Date Signed
Ohio Department of Health Concussion Information Sheet
For Youth Sports Organizations
Dear Parent/Guardian and Athletes,
This information sheet is provided to assist you and your child in recognizing the signs and symptoms of a concussion. Every athlete is different and responds to a brain injury differently, so seek medical attention if you suspect your child has a concussion. Once a concussion occurs, it is very important your athlete return to normal activities slowly, so he/she does not do more damage to his/her brain.
What is a Concussion?
A concussion is an injury to the brain that may be caused by a blow, bump, or jolt to the head. Concussions may also happen after a fall or hit that jars the brain. A blow elsewhere on the body can cause a concussion even if an athlete does not hit his/her head directly. Concussions can range from mild to severe, and athletes can get a concussion even if they are wearing a helmet.
Signs and Symptoms of a Concussion
Athletes do not have to be “knocked out” to have a concussion. In fact, less than 1 out of 10 concussions result in loss of consciousness. Concussion symptoms can develop right away or up to 48 hours after the injury. Ignoring any signs or symptoms of a concussion puts your child’s health at risk!
Signs Observed by Parents of Guardians
Appears dazed or stunned.
Is confused about assignment or position. Forgets plays.
Is unsure of game, score or opponent. Moves clumsily.
Answers questions slowly.
Loses consciousness (even briefly).
Shows behavior or personality changes (irritability, sadness, nervousness, feeling more emotional). Can’t recall events before or after hit or fall.
Symptoms Reported by Athlete
Any headache or “pressure” in head. (How badly it hurts does not matter.) Nausea or vomiting.
Balance problems or dizziness. Double or blurry vision.
Sensitivity to light and/or noise
Feeling sluggish, hazy, foggy or groggy. Concentration or memory problems.
Does not “feel right.” Trouble falling asleep.
Sleeping more or less than usual.
Encourage your athlete to be honest with you, his/her coach and your health care provider about his/her symptoms. Many young athletes get caught up in the moment and/or feel pressured to return to sports before they are ready. It is better to miss one game than the entire season… or risk permanent damage!
Seek Medical Attention Right Away
Seeking medical attention is an important first step if you suspect or are told your child has a concussion. A qualified health care professional will be able to determine how serious the concussion is and when it is safe for your child to return to sports and other daily activities.
No athlete should return to activity on the same day he/she gets a concussion.
Athletes should NEVER return to practices/games if they still have ANY symptoms. Parents and coaches should never pressure any athlete to return to play.
The Dangers of Returning Too Soon
Returning to play too early may cause Second Impact Syndrome (SIS) or Post-Concussion Syndrome (PCS). SIS occurs when a second blow to the head happens before an athlete has completely recovered from a concussion. This second impact causes the brain to swell, possibly resulting in brain damage, paralysis, and even death. PCS can occur after a second impact. PCS can result in permanent, long-term concussion symptoms. The risk of SIS and PCS is the reason why no athlete should be allowed to participate in any physical activity before they are cleared by a qualified health care professional.
A concussion can affect school, work, and sports. Along with coaches and teachers, the school nurse, athletic trainer, employer, and
other school administrators should be aware of the athlete’s injury and their roles in helping the child recover.
During the recovery time after a concussion, physical and mental rest are required. A concussion upsets the way the brain normally works and causes it to work longer and harder to complete even simple tasks. Activities that require concentration and focus may make symptoms worse and cause the brain to heal slower. Studies show that children’s brains take several weeks to heal following a concussion.