this file

- MINOR (PARTICIPANTS UNDER 18) USA RUGBY PARTICIPATION AGREEMENT AND WAIVER AND RELEASE OF LIABILITYPLEASE READ CAREFULLY
BEFORE SIGNING. THIS IS A RELEASE OF LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS AND ASSUMPTION OF THE RISKS
AGREEMENT.
This Participation Agreement and Waiver and Release of Liability is entered into between the undersigned “Parent” or “Guardian” and the minor
participant “Participant” and USA Rugby, it’s member unions, clubs, organizations, affiliates, partners, sponsors, vendors, directors, officers,
employees, volunteers, members, agents, contractors, contracted entities and facilities and the owners and lessors thereof, hereinafter referred to as
“USA Rugby” or collectively as “Releasees”).
In consideration for the privilege of participation of the Participant in USA Rugby activities, Participant, Parent or Guardian acknowledge and agree as
follows:
1.
Participation in the activities of USA Rugby, including but not limited to warm-up, training, practice, games, clinics, travel, and social events (referred
to herein as the “Activities”), includes participation in a full-contact sport, requires good health and fitness and can be HAZARDOUS AND PRESENT
A DANGER TO PARTICIPANT. Participant and Parent or Guardian believe the Participant is qualified to participate in Activities, and if at any time the
Participant, Parent or Guardian believe conditions to be unsafe, he/she will immediately discontinue further participation in the Activities _______,
_______, _______INITIAL HERE
2.
Participation in Activities exposes Participant to RISKS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND
DEATH. Risks may arise out of contact and/or participation with other participants, spectators, equipment, field, facility and/or fixed objects; falls,
collisions, rough play, and other mishaps; exposure to adverse weather conditions and/or high altitude; flaws and defects in equipment and facilities;
irregular field conditions; and negligent field maintenance, negligent officiating, negligent coaching and negligent participation. Risks may be caused
by the Participant’s own actions, or inaction, the actions or inaction of others participants, the condition of the facilities in which the Activities take
place, and/or THE NEGLIGENCE OF THE “RELEASEES.” Some Risks cannot be predicted or controlled. There may be other risks and social and
economic losses either not known to me or not readily foreseeable at this time. _______, _______, _______INITIAL HERE
3.
Assumption of the Risks. I CONSENT TO PARTICIPATION IN THE ACTIVITIES AND FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND
ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES incurred as a result of such participation. _______, _______, _______INITIAL
HERE
4.
Waiver and Release of Liability. In consideration for the privilege of the Participant’s participation in the Activities, each undersigned hereby
RELEASES, DISCHARGES, COVENANTS NOT TO SUE, AND AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS RELEASEES from
any and all liability, demands, losses, medical expenses, lost opportunities, damages or attorneys fees and costs stemming from any or all claims for
negligence, expressed or implied warranty, contribution, and indemnity, and/or claims of negligent rescue operations, first aid, and emergency care, to
the broadest extent permitted by applicable law, including C.R.S. § 13-22-107, suffered by the Participant, Parent or Guardian or incurred on his/her
account with respect to the Participant’s personal injury and other injury or harm, disability, and/or death, or property damage, arising directly or
indirectly from the Participant’s participation in Activities, as caused or alleged to be caused in whole or in part by the Releasees or any of them, and
further agrees that if, despite this release, the Participant or any other person makes a claim on the Participant’s behalf against any of the Releasees,
THE UNDERSIGNED WILL INDEMNIFY, SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LIABILITY, LITIGATION
EXPENSES, ATTORNEY FEES, LOSSES, DAMAGES OR COSTS ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM, WHETHER
ASSERTED BY THE UNDERSIGNED, THE PARTICIPANT, OR ANOTHER PERSON. ________ , _______, _______INITIAL HERE
5.
Governing Law, Venue and Jurisdiction: The undersigned understands and agrees that this document is intended to be as broad and inclusive as
permitted under applicable law and shall be governed by Colorado law. In the event of a dispute, the exclusive venue and jurisdiction for any lawsuit
arising out of such dispute shall be the state court of Boulder County, or the federal courts located in Denver, Colorado. ______, _______,
_______INITIAL HERE
6.
Severability: If any provision of this document is determined to be invalid for any reason, such invalidity shall not affect the validity of any of the other
provisions, which other provisions shall remain in full force and effect as if this document had been executed with the invalid provision eliminated.
________, _______, _______INITIAL HERE
THE UNDERSIGNED PARTCIPANT AND PARENT AND/OR GUARDIAN HEREBY CERTIFY THAT PARTICIPANT IS UNDER 18 YEARS OLD,
THAT I HAVE COMPLETELY READ AND UNDERSTAND THIS AGREEMENT AND ITS TERMS. THAT PRIOR TO SIGNING THIS AGREEMENT,
I HAVE HAD THE OPPORTUNITY TO ASK ANY QUESTIONS ABOUT THIS AGREEMENT. I AM AWARE, BY SIGNING THIS AGREEMENT I
ASSUME ALL RISKS AND WAIVE AND RELEASE CERTAIN RIGHTS THAT I AND EACH OF MY HEIRS, NEXT OF KIN, FAMILY, RELATIVES,
GUARDIANS, CONSERVATORS, EXECUTORS, ADMINISTRATORS, TRUSTEES AND ASSIGNS MAY HAVE AGAINST RELEASEES.
_____________________________________________________________________________________________________________________
Parent/Guardian Signature
Printed Name
Date
I AM A PARENT/GUARDIAN OF THE PARTICIPANT, AND I ATTEST THAT I HAVE LEGAL RESPONSIBILITY OVER THE PARTICIPANT, AND,
MY SIGNATURE IS SUFFICIENT TO CONSENT TO THE PARTICIPATION OF THE PARTICIPANT IN THE ACTIVITIES AND TO ENTER INTO
THIS AGREEMENT FOR AND ON BEHALF OF THE PARTICIPANT.
_____________________________________________________________________________________________________________________
Parent/Guardian Signature
Printed Name
Date
_____________________________________________________________________________________________________________________
Witness
Printed Name
Date
***PLEASE
PRINT, INITIAL, SIGN AND RETURN TO YOUR AFFILIATED CLUB***
- MINOR (PARTICIPANTS UNDER 18) USA RUGBY (MINOR) USA RUGBY RULES ACKNOWLEDGEMENT
1.
2.
3.
The Minor will abide by all International Rugby Board, USA Rugby, territorial and local area union rules and regulations, including the arbitration
procedures therein, for any dispute regarding the Minor’s eligibility or right to participate in, USA Rugby-sponsored and –sanctioned activities and
events, as set forth in the Bylaws of USA Rugby, as they are amended on a periodic basis, which are available on the USA Rugby web site
(www.usarugby.org).
I affirm that the Minor is not suspended or banned from play or participation by any club, local area union, territorial union, or national union, and
I authorize USA Rugby to verify the Minor’s citizenship status with the appropriate governmental agencies
I am aware that USA Rugby has the right to revoke the Minor’s CIPP enrollment, and therefore his/her eligibility to play or coach, in the event of
any violation of the aforementioned statement.
I HAVE CAREFULLY READ THIS ACKNOWLEDGMENT AND BY SIGNING BELOW AGREE TO ALL OF ITS TERMS. I SIGN THIS DOCUMENT
VOLUNTARILY AND WITH FULL UNDERSTANDING OF ITS TERMS AND LEGAL SIGNIFICANCE. I AM A PARENT/GUARDIAN OF THE
MINOR, AND I ATTEST THAT I HAVE LEGAL RESPONSIBILITY OVER THE MINOR, AND FURTHER ATTEST THAT, IF I AM THE SOLE
PARENT/GUARDIAN SIGNING BELOW, MY SIGNATURE IS SUFFICIENT TO CONSENT TO THE PARTICIPATION OF THE MINOR IN THE
ACTIVITIES AND TO ENTER INTO THIS AGREEMENT ON BEHALF OF THE MINOR.
PROVIDE NAME OF MINOR:
_______________________________________________________________________
________________________________________________________________________________________________________________
Parent/Guardian Signature
Printed Name
Date
________________________________________________________________________________________________________________
Parent/Guardian Signature
Printed Name
Date
***PLEASE
PRINT, INITIAL, SIGN AND RETURN TO YOUR AFFILIATED CLUB***
All clubs are required to maintain the signed waivers & releases in their possession for a minimum
of three (3) years and provide to USA Rugby at any time upon request.
For more information about USA Rugby's Liability Insurance protection, please visit:
www.usarugby.org.
Parent/Guardian Agreement
PARENTAL CONSENT FOR TREATMENT OF MINORS
I, as the parent or legal guardian of a minor, hereby authorize a representative of Mobile Area Rugby Foundation, Inc., referred to
herein as MARF, to seek medical and/or surgical treatment for my son/daughter as may be deemed medically necessary in order
to assure his/her safety. It is distinctly agreed and understood that the representative of MARF, shall not be responsible in any way
for any consequences from said diagnostic, medical and/or surgical treatment.
WAIVER OF LIABILITY AND ELIGIBILITY FOR RUGBY PARTICIPATION
The undersigned states:
1. To the best of my knowledge and belief, I am eligible under USA Rugby Guidelines (CIPP registered) to participate in
this activity.
2. To the best of my knowledge and belief, I am eligible to participate in this activity under all applicable local area
governing organization guidelines.
3. I agree to abide by all rules and regulations imposed by the International Rugby Board, USA Rugby, the local governing
organization and the local host.
4. I am aware that I may lose the privilege to participate in the activity in the event of any violation of the above
mentioned statements.
5. I am aware that rugby is a contact sport and participation may result in permanent disability, social and economic loss,
and even death. These risks may arise as a result of my own actions or inaction's, or may arise from the actions or
inaction's of others, or may arise from rules applied to the activity, condition of the premises, and/or equipment used.
I FULLY ACCEPT ALL SUCH RISKS AND RESPONSBILITIES FOR LOSSES, COSTS, AND DAMAGES incurred as a result of my
Participation in the Activity.
6. I release, waive, discharge, and covenant not to sue USA Rugby, local governing organizations, referee associations,
affiliated clubs, their respective administrators, directors, agents, coaches, referees, and other employees of the
organizations, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and leases of
premises to conduct all rugby activities, all of which hereinafter, referred to as "releases", from demands, losses or
damages on account of injury, including death or damage to property caused or alleged to be caused in whole or part by
negligence of the release of otherwise.
7. I understand that it may be necessary for MARF to transport the player, or to use transportation not provided by
MARF, in order for player to attend or participate in MARF activities/events. I agree to defend, indemnify, and hold MARF,
its trustees, agents, employees and affiliated entities harmless from any and all damages, including, but not limited to,
bodily injuries and property damage that may arise from player transportation to MARF activities/events.
8. My signature on this form acknowledges my receipt of the CDC Concussion in youth sports fact sheet which outlines:
the nature and risk of concussion and head injury to student athletes, provides the signs and symptoms of concussion,
prevention advice, offers instruction on steps to take with a suspected concussion, and includes the risks of continuing
to play after concussion or head injury.
__________________________________________________
Player Name
__________________________________________________
Parent Signature
__________________________________________________
Date
U.S. D EPARTMENT
OF H EALTH AND H UMAN S ERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
A Fact Sheet for PARENTS
WHAT IS A CONCUSSION?
A concussion is a brain injury. Concussions are caused
by a bump or blow to the head. Even a “ding,” “getting
your bell rung,” or what seems to be a mild bump or
blow to the head can be serious.
You can’t see a concussion. Signs and symptoms of
concussion can show up right after the injury or may
not appear or be noticed until days or weeks after the
injury. If your child reports any symptoms of concussion,
or if you notice the symptoms yourself, seek medical
attention right away.
WHAT ARE THE SIGNS AND
SYMPTOMS OF A CONCUSSION?
July 2007
Signs Observed by Parents or Guardians
If your child has experienced a bump or blow to the
head during a game or practice, look for any of the
following signs and symptoms of a concussion:
• Appears dazed or stunned
• Is confused about assignment or position
• Forgets an instruction
• Is unsure of game, score, or opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows behavior or personality changes
• Can’t recall events prior to hit or fall
• Can’t recall events after hit or fall
Symptoms Reported by Athlete
• Headache or “pressure” in head
• Nausea or vomiting
• Balance problems or dizziness
• Double or blurry vision
• Sensitivity to light
• Sensitivity to noise
• Feeling sluggish, hazy, foggy, or groggy
• Concentration or memory problems
• Confusion
• Does not “feel right”
HOW CAN YOU HELP YOUR CHILD
PREVENT A CONCUSSION?
Every sport is different, but there are steps your children
can take to protect themselves from concussion.
• Ensure that they follow their coach’s rules for
safety and the rules of the sport.
• Encourage them to practice good sportsmanship
at all times.
• Make sure they wear the right protective equipment
for their activity (such as helmets, padding, shin
guards, and eye and mouth guards). Protective
equipment should fit properly, be well maintained,
and be worn consistently and correctly.
• Learn the signs and symptoms of a concussion.
WHAT SHOULD YOU DO IF YOU THINK
YOUR CHILD HAS A CONCUSSION?
1. Seek medical attention right away. A health
care professional will be able to decide how serious
the concussion is and when it is safe for your child
to return to sports.
2. Keep your child out of play. Concussions take
time to heal. Don’t let your child return to play
until a health care professional says it’s OK.
Children who return to play too soon—while the
brain is still healing—risk a greater chance of
having a second concussion. Second or later
concussions can be very serious. They can cause
permanent brain damage, affecting your child for
a lifetime.
3. Tell your child’s coach about any recent
concussion. Coaches should know if your child
had a recent concussion in ANY sport. Your
child’s coach may not know about a concussion
your child received in another sport or activity
unless you tell the coach.
It’s better to miss one game than the whole season.
For more information and to order additional materials free-of-charge, visit:
www.cdc.gov/ConcussionInYouthSports
For more detailed information on concussion and traumatic brain injury, visit:
www.cdc.gov/injury
D EPARTAMENTO
DE S ALUD Y S ERVICIOS H UMANOS DE LOS E STADOS U NIDOS
CENTROS PARA EL CONTROL Y L A PREVENCIÓN DE ENFERMEDADES
Hoja Informativa para los PADRES
¿QUÉ ES LA CONMOCIÓN CEREBRAL?
Una conmoción cerebral es una lesión en el cerebro, causada
por un golpe en la cabeza o una sacudida. Incluso una pequeña
conmoción o lo que parece ser un golpe o sacudida leve puede
ser serio.
La conmoción cerebral no puede verse. Los signos y síntomas de
una conmoción pueden aparecer inmediatamente después de la
lesión o puede que no aparezcan, o se hagan visibles algunos días
o meses después de haber sufrido la lesión. Si su hijo tiene los
signos de una conmoción cerebral o si usted nota algún síntoma,
busque atención médica de inmediato.
Julio de 2007
Versión en español aprobada por CDC Multilingual Services – Order # 4421
¿CUÁLES SON LOS SIGNOS Y SÍNTOMAS DE LA
CONMOCIÓN CEREBRAL?
Signos que notan los padres y los tutores
Si su hijo ha sufrido un golpe en la cabeza o una sacudida
durante un juego o una práctica, obsérvelo para determinar si
tiene alguno de los siguientes signos y síntomas de una
conmoción cerebral:
• Luce aturdido o fuera de control
• Se confunde con la actividad asignada
• Olvida las jugadas
• No se muestra seguro del juego, la puntuación ni de sus
adversarios
• Se mueve con torpeza
• Responde con lentitud
• Pierde el conocimiento (así sea momentáneamente)
• Muestra cambios de conducta o de personalidad
• No puede recordar lo ocurrido antes de un lanzamiento
o un caída
• No puede recordar lo ocurrido después de un lanzamiento
o un caída
Síntomas que reporta el atleta
• Dolor o "presión" en la cabeza
• Náuseas o vómitos
• Problemas de equilibrio, mareo
• Visión doble o borrosa
• Sensibilidad a la luz y al ruido
• Se siente débil, confuso, aturdido o grogui
• Problemas de concentración o memoria
• Confusión
• No se "siente bien"
¿CÓMO AYUDAR A SU HIJO A PREVENIR UNA
CONMOCIÓN CEREBRAL?
Aunque todo deporte es diferente, hay medidas que puede tomar
para protegerse.
• Haga que siga las reglas impartidas por el entrenador y las
reglas del deporte que practica.
• Invítelo a mantener el espíritu deportivo en todo momento.
• Haga que su hijo use el equipo protector adecuado según la
actividad que realiza (como casco, almohadillas protectoras,
canilleras o protector dental). El equipo de protección debe
ajustarse bien, debe hacérsele el mantenimiento adecuado, y
el jugador debe usarlo correctamente y en todo momento.
• Aprenda a identificar los signos y síntomas de la conmoción.
¿QUÉ DEBE HACER SI CREE QUE SU HIJO HA SUFRIDO
UNA CONMOCIÓN CEREBRAL?
1. Busque atención médica de inmediato. Un profesional
de la salud podrá determinar la seriedad de la conmoción
cerebral que ha sufrido el niño y cuándo podrá regresar al
juego sin riesgo alguno.
2. No permita que su hijo siga jugando. Las conmociones
cerebrales necesitan de un cierto tiempo para curarse. No
permita que su hijo regrese al juego hasta que un profesional
de la salud le haya dicho que puede hacerlo. Los niños que
regresan al juego antes de lo debido - mientras el cerebro
está en proceso de curación - corren un mayor riesgo de
sufrir otra conmoción. Las conmociones cerebrales siguientes
pueden ser muy serias. Pueden causar daño cerebral
permanente que afectarán al niño de por vida.
3. Informe al entrenador del niño sobre cualquier
conmoción cerebral que el niño haya sufrido
recientemente. Los entrenadores deben saber si el niño
ha sufrido una conmoción recientemente en CUALQUIER
deporte. El entrenador no necesariamente sabrá si el niño
ha tenido una conmoción en otro deporte o actividad a
menos que usted se lo diga.
Es preferible perderse un juego que toda la temporada.
Para obtener más información o solicitar más materiales de forma gratuita, visite:
www.cdc.gov/ConcussionInYouthSports
Para obtener información más detallada sobre la conmoción cerebral y la
lesión cerebral traumática, visite: www.cdc.gov/injury