Team Ryano Kilkenny Health & Safety Update 2021

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Name
First Name
Last Name
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1. History of heart problems (i.e. chest pains, heart murmur, stroke)
YesNo
3
2. Diabetes (Type 1 or 2)
YesNo
4
3. Asthma, breathing or lung problems
YesNo
5
4. Allergies
YesNo
6
5. Cancer
YesNo
7
6. Seizures, neurological problems or dizziness
YesNo
8
7. High or low blood pressure
YesNo
9
8. Back Pain
YesNo
10
9. Joint pain or muscle disorder aggravated by exercise
YesNo
11
10. Hernia or any other condition aggravated by exercise
YesNo
12
11. History of high cholesterol
YesNo
13
12. Family history of coronary heart disease
YesNo
14
13. Do you smoke
YesNo
15
14. Do you consume alcohol
YesNo
16
15. If yes how many units per week?
17
16. Do you take supplements of any kind, (state below)
YesNo
18
State below what supplements
19
17. Are you currently on any medication
YesNo
20
18. Are you currently pregnant
YesNo
21
Important Notice: If you proceed with a programme of physical activity and, during that period your health changes so that you subsequently answered YES to any of the above questions please notify us immediately, as you may need to change, or even suspend your physical activity plan.
I accept
I don’t accept
22
Covid-19I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Team Ryano Kilkenny has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Team Ryano Kilkenny can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients/members and their families. I voluntarily seek services provided by Team Ryano Kilkenny and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I attest that: * I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. * I have not traveled internationally within the last 14 days. * I have not traveled to a highly impacted area within Ireland in the last 14 days. * I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. * I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities. * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold Team Ryano Kilkenny harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the facility, or that may otherwise arise in any way in connection with any services received from Team Ryano Kilkenny. I understand that this release discharges Team Ryano Kilkenny from any liability or claim that I, my heirs, or any personal representatives may have against the facility with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Team Ryano Kilkenny. This liability waiver and release extends to the facility together with all owners, partners, and employees.
I acceptI don't accept
23
Release and Waiver of Liability and Indemnity AgreementIn consideration of being permitted to participate in any way in the Martial Arts Program indicated below and/or being permitted to enter for any purpose any restricted area (here in defined as any area where in admittance to the general public is prohibited), the adult participant named below agrees, or the parent(s) and/or legal guardian(s) of the minor participant named below agree: 1. The parent(s) and/or legal guardian(s) will instruct the minor participant that prior to participating in the below martial arts activity or event, he or she should inspect the facilities and equipment to be used, and if he or she believes anything is unsafe, the participant should immediately advise the officials of such condition and refuse to participate. I understand and agreed that, if at any time, I feel anything to be UNSAFE, I will immediately take all precautions to avoid the unsafe area and REFUSE TO PARTICIPATE further. 2. I/WE fully understand and acknowledge that: (a) There are risks and dangers associated with participation in martial arts events and activities which could result in bodily injury, partial and/or total disability, paralysis and death; (b) The social and economic losses and/or damages, which could result from these risks and dangers described above, could be severe; (c) These risks and dangers may be caused by the action, inaction or negligence of the participant or the action, inaction or negligence of others, including, but not limited to, the Releasees named below; and (d) There may be other risks not known to us which are not reasonably foreseeable at his time. 3. I/WE accept and assume such risks and responsibility for any losses and/or damages following such injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Releasees named below. 4. I/WE HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the martial arts facility used by the participant, including its owners, managers, promoters, lessees of premises used to conduct the martial arts event or program, premises and event inspectors, underwriters, consultants and others who give recommendations, directions, or instructions to engage in risk evaluation or loss control activities regarding the martial arts facility or events held at such facility and each of them, their directors, officers, agents, employees, all for the purposes herein referred to as “Releasee”...FROM ALL LIABILITY TO THE UNDERSIGNED, my/our personal representatives, assigns, executors, heirs and next to kin FOR ANY AND ALL CLAIMS, DEMANDS, LOSSES OR DAMAGES AND ANY CLAIMS OR DEMANDS THEREFORE ON ACCOUNT OF ANY INJURY, INCLUDING BUT NOT LIMITED TO THE DEATH OF THE PARTICIPANT OR DAMAGE TO PROPERTY, ARISING OUT OF OR RELATING TO THE EVENT(S) CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEE OR OTHERWISE. 5. I/WE HEREBY acknowledge that THE ACTIVITIES OF THE EVENT(S) ARE VERY DANGEROUS and involve the risk of serious injury and/or death and/or property damage. Each of THE UNDERSIGNED also expressly acknowledges that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES. 6. I/WE give full permission, in perpetuity, for media, including but not limited to audio, photographs, and video, to be taken of me during martial arts program events, and to be used in promotion of the program. I/WE understand that there will be no compensation for such use, and I/WE release all claims to any and all damages resulting from such use. 7. EACH OF THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Province or State in which the event is conducted and that if any portion is held invalid, it is agreed that the portion in question shall be severable from the remainder of the agreement and each clauses herein shall accordingly be construed as entirely severable and separately enforceable. 8. On behalf of the participant and individually, I the undersigned alternatively I/WE the partner(s) and/or legal guardian(s) for the minor participant executes this Waiver and Release. If, despite this release, the participant makes a claim against any of the Releasees, the parent(s) and/or legal guardian(s) will reimburse the Releasee for any money which they have paid to the participant, or on his behalf, and hold them harmless. 9. I expressly waive, release and discharge Team Ryano Kilkenny and any affiliates, officers, employees, representatives, agents, contractors, or volunteers of the above (the “Released Parties”) from any and all claims for damages or injuries that I or the participant may sustain as the result of participation in Team Ryano Kilkenny activities. I assume all risk for participation in Team Ryano Kilkenny activities and understand that the Released Parties are not responsible for determining a participant’s fitness to participate. 10. I understand that the Released Parties have made no representations as to the results of participation in Team Ryano Kilkenny activities. I understand further that no representations are being made to me as to the professional qualifications, standards, equipment, or safety associated with participation in Team Ryano Kilkenny activities. 11. The responsibility for the assessment of all risks associated with Team Ryano Kilkenny activities is mine alone, and any damages of any type due to the failures or negligence of others I also accept as my responsibility alone. I assume all attendant risks regardless of my ability to foresee and/or evaluate those risks. The responsibility to be aware of whether a particular activity is an official activity of Team Ryano Kilkenny is also mine alone. I am aware that this information is available to me online and I know where to retrieve this information. 12. I understand that the accident coverage portion of the Team Ryano Kilkenny insurance policy is secondary to my personal health insurance and I understand what that means. I understand that Team Ryano Kilkenny accident coverage is also contingent upon my possession of primary coverage through a health insurance policy of my own, and that Team Ryano Kilkenny will not submit a claim if I do not have primary coverage. I understand that I am responsible for any deductible payments associated with Team Ryano Kilkenny insurance if a claim is submitted for me. I further understand that the submission of any insurance claim is at the sole discretion of Team Ryano Kilkenny. 13. I understand that the liability coverage portion of the HEMA Alliance insurance policy only covers Individual Members of Team Ryano Kilkenny. Team Ryano Kilkenny who are categorized as Staff. It is my responsibility to know whether I fall into this category. I am aware that this information is kept by the Governing Council of Team Ryano Kilkenny and I know how to contact the Governing Council to confirm this information. 14. I agree and understand that Team Ryano Kilkenny has the sole discretion to terminate my membership with immediate affect if I, as a participant, act in any manner that is considered by any member of Team Ryano Kilkenny to be overly aggressive and or if I could be considered a potential harm to other participants. Such discretion lies solely with the staff at Team Ryano Kilkenny and the above examples are not exhaustive. Team Ryano Kilkenny reserves the right to terminate any membership with immediate affect if deems necessary, for whatever reason. 15. I understand that while instructors may announce a requirement of certain protective gear for certain activities, the student always has the option and responsibility to add protective gear that the student considers necessary or desirable. I further understand that eye protection and other protective gear are always available for students to borrow, and that it is my responsibility to ask for these. I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. Martial Arts School: Team Ryano Kilkenny
I acceptI don't accept
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Photo Waiver Release I hereby irrevocably authorize Team Ryano Kilkenny to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. I hereby hold harmless, release, and forever discharge Team Ryano Kilkenny from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT:
I accept I don't accept
25
Client Declaration: I have read, fully understand, and have completed this questionnaire. The answers I have given are accurate to the best of my knowledge.
I accept
I don’t accept
26
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