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MEDICAL RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT (“Agreement”)

 

Today's Date: May 18, 2021

In consideration of being permitted to be present at, attend, observe, and participate in activities at the facilities of, or provided by, Boulder County Soccer Club (the "Activities") I, for myself for and for my child(ren) (collectively referred to herein as “me” “I” or “my”), personal representatives, assigns and heirs: 

  1. Acknowledge, agree, and represent that I understand the nature of the Activities and that I am qualified, in good health, and in proper physical condition to participate in them. I further agree and warrant that if at any time I believe conditions to be unsafe, or if at any time my health suffers, I will immediately discontinue participation, and leave if appropriate.
  2. Authorize Boulder County Soccer Club, its respective owners, investors, members, managers, shareholders, agents, directors, officers, volunteers, employees, landowners, subsidiaries, and affiliated companies (collectively, "Releasees") and medical care provider(s) to carry out any emergency medical transport or medical care for me, as may be necessary in their sole discretion, and agree to be fully responsible for any costs associated with such transport and care.
  3. Understand that it is my responsibility to comply with all posted and published procedures, including safety and hygiene procedures and protocols intended to lessen the likelihood of the spread of disease among participants and staff.  I further understand that it is my responsibility to comply with all laws and other requirements imposed by federal, state, and local authorities.
  4. UNDERSTAND THAT THE ACTIVITIES INVOLVE INHERENT AND OTHER RISKS AND DANGERS, including but not limited to falling or loss of balance; striking padded or unpadded surfaces; being injured by equipment; being injured by the actions or inactions of other participants and bystanders; collisions with other participants; falls due to slick or uneven surfaces; equipment failures of any kind; equipment misuse by myself or others; potential exposure to communicable disease (including but not limited to coronavirus/COVID-19, other viruses, bacteria, and all other infectious pathogens and disease vectors); physical injury or illness as a result of physical activity or being on the premises where the Activities take place; and which risks may result in SERIOUS INJURY, ILLNESS, EMOTIONAL DISTRESS, AND DEATH (collectively, "Risks").  I understand that the Risks may be caused or contributed to by my own actions or inactions, the actions or inactions of other participants, bystanders or staff, the conditions and settings in which the Activities take place, or the alleged or actual NEGLIGENCE of the Releasees.  I understand that the description and list of Risks in this Agreement is not complete, and that I will encounter Risks not described herein, known and unknown, inherent and otherwise, in connection with the Activities.  With a full understanding of the foregoing, I VOLUNTARILY AGREE TO ASSUME ALL INHERENT AND OTHER RISKS OF INJURY, ILLNESS, EMOTIONAL DISTRESS, AND DEATH AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of, or in connection with, the Activities. 
  5. RELEASE, DISCHARGE, HOLD HARMLESS, AND AGREE NEVER TO SUE RELEASEES FOR ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ARISING FROM OR RELATED TO ACTIVITIES, INCLUDING INJURY, ILLNESS, EMOTIONAL DISTRESS, OR DEATH CAUSED IN WHOLE OR IN PART BY THE ALLEGED OR ACTUAL NEGLIGENCE OF THE RELEASEES.  I further agree that if, despite this Agreement, I or anyone acting on my behalf makes a claim against any of the Releasees, I will DEFEND, INDEMNIFY, AND HOLD HARMLESS each of the Releasees from any attorneys’ fees, losses, liability, damage, or expenses which Releasees may incur as the result of such claim. 
  6. I understand that this Agreement will apply every time I am on the premises of City of Boulder facilities or participate in the Activities.  I agree that this Agreement is a contract which will be enforced to the fullest extent allowed by law and will be binding on me, my assignees, subrogees, heirs, assigns, executors, and personal representatives.  If any part of this Agreement is deemed to be unenforceable, the remaining terms shall be enforceable. 
  7. Recognizing the possibility of injury or illness, and in consideration for US Youth Soccer and members of US Youth Soccer accepting my son/daughter as a player in the soccer programs and activities of US Youth Soccer and its members (the "Programs"), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify US Youth Soccer, 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 behalf of my player son/daughter as a result of my son's/daughter’s participation in the Programs and/or being transported to or from the Programs.
  8. I hereby authorize the emergency transportation of my son/daughter to or from the Programs.
  9. My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of participating in the sport of soccer.
  10. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child's participation in the Programs.
  11. I give my consent to have an athletic trainer and/or licensed medical doctor or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.

I Agree
I have read this agreement and fully understand and agree to be bound to its terms. I understand that I have given up substantial legal rights by signing it, and have signed it freely and without inducement or assurance of any nature.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating player and agree that they and the player are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Allergies

Other Medical Conditions

Player's Physician *

Physician Phone *

Medical and/or Hospital Insurance Company *

Medical and/or Hospital Insurance Company Phone *

Policy Holder *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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