Return to Play New Client Intake Form
Athlete Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
DOB:
Gender
Please Select
Male
Female
Race/Ethnicity
Type of Injury
Name of PT
Please Select
Ronnie P
Paul S
Jared G
Jess W
Mark G
Matt M
Katie L
Ryan P
Surgery Date (If Any)
Name of Surgeon
Waiver of Liability SPORTS ACADEMY LLC (hereinafter referred to as "SPORTS ACADEMY") is a multi-purpose sports, training, and recreation center that provides a wide variety of sports and activities for participants of all ages both onsite (the “Main Campus”) and offsite at other facilities that may be owned, leased, operated and/or used by SPORTS ACADEMY (collectively referred to herein as the “Other Facilities”, and together with the Main Campus, referred to herein as the “Facilities”). Some of the activities offered include, without limitation, instruction, leagues, tournaments, fitness activities (including yoga, individualized personal training and group fitness classes), self-defense (Close Quarters Defense®) classes, parent/child classes, summer camps, birthday parties, field trips, corporate outings, team building events, and company picnics (hereinafter collectively referred to as "Activities"). The Facilities are also available for individual, team and/or group rental. Some of the many benefits of SPORTS ACADEMY Activities include improved fitness, opportunity to compete and excel, improved self-confidence, better health, increased sense of belonging, wholesome recreation, social interaction, improved self-image, weight loss, and improved appearance. The physical exertion required ranges from mild to very strenuous, depending on the activity and the motivation of the participant; the skill level required ranges from beginner to highly advanced, depending on the activity and competition; and the competitiveness of the activity ranges from moderate to highly competitive. Therefore, the individual participant is able to select Activities that fit his or her needs, abilities, and interests.While the many benefits of these Activities are apparent, SPORTS ACADEMY and its staff regard participant safety as a top priority and feel it is important that the Participant/Parent [either an adult Participant OR a minor Participant and his/her parent(s)/guardian(s)] understand that there are risks inherent in all physical activity. SPORTS ACADEMY takes great care to reduce the risks associated with the many physical activities offered at the Facilities. However, regardless of the care taken to avoid injuries, some risks are inherent in any physical activity and cannot be totally eliminated without changing the nature of the activity. A few examples of the many inherent risks include, but are not limited to, heat-related illness; over-exertion; imperfect playing surfaces; failure to adhere to posted rules or warnings (Note: coaches or supervisors may be present for certain activities, but the Participant/Parent should have no expectation of supervision over an area or activity unless expressly specified otherwise); collisions with objects or co-participants; falls to the playing surface; unexpected equipment failure or malfunction (e.g., obstacles, fitness equipment, pitching machines, etc.); careless or erratic acts by co-participants; errors in judgment/supervision of supervisors, other employees, or officials; and being struck by an object (e.g. ball, puck, bat, stick, etc.). There are also inherent risks that are specific to a sport or activity – such as being kicked by a co-participant in soccer; being hit by a ball in basketball or volleyball; body contact in basketball; and, in the case of Close Quarters Defense training and instruction, physical contact including, but not limited to, kicking, punching, elbowing and other intentional acts that are otherwise intended to injure others. There are even inherent risks in being a spectator of a sport (e.g. being hit by a ball or participant, falling down stairs, etc.) or in non-sports Activities (i.e., birthday parties, camps, or team-building activities) and injuries can occur due to the enthusiasm of participants, reckless conduct, or failure to follow posted rules. The undersigned acknowledges that the Participant should be evaluated by his/her physician prior to participating in the Activities.SPORTS ACADEMY believes that it is important that the Participant/Parent understand that these types of injuries can occur. Minor injuries are the most common and include, but are not limited to, muscle soreness, headaches, sprains/strains, abrasions, and bruises. Serious injuries are less common, but do occur occasionally. They include, but are not limited to, broken bones, concussions, torn ligaments or cartilage, eye injuries, cuts, and internal injuries. Catastrophic injuries are very rare, but SPORTS ACADEMY believes that every Participant/Parent should be aware of the slight possibility. Catastrophic injuries may include permanent disability and/or disfigurement, brain injury, paralysis and even death.The undersigned Participant/Parent warrants and represents that he/she possesses the authority to execute this Waiver of Liability/Release of Claims on behalf of the above-named Participant. Participant/Parent acknowledges that Participant will be participating in and/or attending Activities at one or more of the Facilities.ASSUMPTION OF RISKS: I, the undersigned Participant/Parent, understand that all Activities provided by SPORTS ACADEMY at the Facilities inherently involve the risk of bodily injury, including death, regardless of the care taken by SPORTS ACADEMY. By signing this waiver, Participant/Parent acknowledges that he/she has read and understood this Waiver of Liability and Release of Claims and that he/she knows, understands, and appreciates the risks and types of injuries inherent in the Activities. The Participant/Parent hereby acknowledges that participation in the Activities is voluntary and he/she knowingly assumes all inherent risks of the Activities, today and on all future dates.WAIVER OF LIABILITY FOR CONDUCT OF SPORTS ACADEMY: In consideration of permission to use the Facilities, equipment, and services of SPORTS ACADEMY, today and on all future dates, I, the Participant/Parent, on behalf of myself, my spouse, heirs, executors, administrators, personal or legal representatives, and assigns (hereinafter collectively referred to as the "Releasing Parties") do hereby waive, release, discharge and covenant not to sue SPORTS ACADEMY (including Sports Academy LLC, Sports Academy Venture Lab, SA Legends Lacrosse, Sports Academy Foundation) and all owners, officers, directors, members, partners, employees, agents, volunteers, parent companies, subsidiaries, affiliates, representatives, independent contractors, and equipment suppliers thereof; hereinafter collectively referred to as the "Releasees" from liability for any and all claims, demands, actions, losses, damages, injuries, or liabilities of any kind or nature, to the fullest extent allowed under the law, which are sustained, suffered or incurred by the Participant as a result of his/her participation in and/or attendance at any of the Activities in, on or around any of the Facilities. I, the Participant/Parent, on behalf of the Releasing Parties, further expressly assume all risks associated with participation in and/or attendance at the Activities in, on or around any of the Facilities.This Waiver of Liability & Release of Claims applies to: (1) personal injury (including death) from incidents or illnesses arising from participation in SPORTS ACADEMY Activities including, but not limited to, recreational, practice, or competitive Activities; events; organized or individual training and conditioning Activities; individual or group instruction; as an observer or spectator; and individual use of all Facilities, including, without limitation, the associated sidewalks and parking lots of the Facilities, and/or equipment; and (2) any and all claims resulting from damage to, loss of, or theft of property.INDEMNIFICATION: Participant shall indemnify, defend and hold harmless the Releasees from and against any and all Claims resulting from, arising out of or in connection with Participant’s use of the Facilities and/or equipment, participation in and/or attendance at the Activities and/or Participant’s conduct and/or actions before, during and/or after the Activities (whether intentional or otherwise), whether resulting in whole or in part from the negligence of any Releasee; provided, however, that the foregoing indemnification shall not apply to any Claims that are ultimately found to have been caused by the willful misconduct of SPORTS ACADEMY. RIGHT OF PUBLICITY/PRIVACY: Participant/Parent acknowledges and understands that photography and/or audio-visual recording of SPORTS ACADEMY Activities can and does occur and, in consideration for the use of the Facilities and participation in and/or attendance at the Activities, Participant/Parent hereby unconditionally and irrevocably agrees to allow SPORTS ACADEMY to photograph and/or record Participant and/or Parent and to use any such photographs or recordings or Participant/Parent's name, likeness, voice, or other personal characteristics in any print, internet, radio television, billboard, social media, or multimedia advertising or marketing or for any commercially reasonable use whatsoever. Participant/Parent, on behalf of himself/herself and all Releasing Parties, hereby releases the Releasees from any and all claims and demands that may arise out of or in connection with the use of the photographs, recordings, or Participant/Parent's name, likeness, voice, or other personal characteristics, including without limitation any and all claims for libel or violation of any right of publicity or privacy.Participant/Parent acknowledges and understands that the Participant’s personal data is collected during participation in the Activities. Personal biometric data collection occurs in various forms, some of which involve sports performance, biomechanical assessments, recovery, sport- specific skill advancement, and questionnaires. SPORTS ACADEMY’s biometric human performance data collection system is HIPAA compliant. In consideration of the use of the Facilities and/or participation in and/or attendance during Activities, Participant/Parent hereby unconditionally and irrevocably agrees to allow SPORTS ACADEMY to collect personal and biometric data and/or record Participant’s personal and biometric data to use in private evaluations, coaching sessions, presentations or educational research.REPORTING OF HARASSMENT, ABUSE and NEGLECT: Participant/Parent further agrees that upon observing or experiencing any harassment, abuse, or neglect, whether it be physical, sexual, emotional, or psychological in nature, he/she shall immediately report such harassment, abuse, or neglect: (1) to the SPORTS ACADEMY supervisor on duty or, (2) if such supervisor participated or was involved in the harassment, abuse, or, neglect, to SPORTS ACADEMY'S Athletic Director, whose contact information is posted and/or is available online at www.sportsacademy.us and at the front desk of the Main Campus.COVID-19: The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.We here at Sports Academy (SA) have put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you will not become infected with COVID-19 while here. We are also asking that you help in the preventative measures that have been put in place so we can reopen.In consideration of being allowed to participate in any training, events, and activities associated with Sports Academy, I the undersigned, acknowledge and agree that:Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and Covid-19. While particular rules and personal discipline my reduce the risk, the risk of serious illness and death does exist; and I knowingly and freely assume all such risk, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility of my participation; and, I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official team member immediately; and, I release, waive, and discharge any and all claims that I or my heirs, assigns, personal representatives, and next of kin, may have now or in the future against the Sports Academy, and its officers, directors, employees, contractors, subcontractors, sponsors, suppliers, other participants, teams, and advertisers of all activities at the Sports Academy; and, if applicable, owners and lessors of the premises used by Sports Academy (“the Releasees”) for any liability, expenses, loss or damage to person or property, injury, death or disability suffered from or in connection with any and all illness, disability, death, or loss or damage to person or property, whether arising from the negligence of releasees or otherwise, to the fullest extent permitted by law.I will not attend any events, sessions, training, etc if I have any reason to feel as if I may have any of the above or other communicable diseases. I will maintain safe social distancing, sanitize my own equipment, etc and follow all guidelines for the health and safety of staff and other members.I attest that I have not travelled outside the USA in the last 30 days, that I have not been in close contact with someone who has travelled outside the USA in the last 30 days, that I have no fever, cough, and/or shortness of breath, that I have not been in close contact with anyone with a laboratory confirmed case of SARS, Corona MERS, and that I authorize Sports Academy to take my temperature when entering in the building. If I answer yes to any of the above, I will follow up with my Primary Care Physician, Urgent Car, or Emergency Room for additional screening.ACKNOWLEDGMENTS TO PROMOTE PARTICIPANT SAFETY: These affirmations aid SPORTS ACADEMY in providing for participant health and safety. Health Status. The Participant/Parent affirms that the Participant:1. Possesses no health problems or physical disabilities that would make participation unwise, or risk injury. 2. Will cease activity and inform SPORTS ACADEMY of any health problem that arises during participation.3. Possesses sufficient skills, coordination, and physical fitness to safely participate.Medical Care. The Participant/Parent affirms that he or she:1. Authorizes SPORTS ACADEMY to secure emergency medical care and transport if deemed necessary; SPORTS ACADEMY does not staff medical personnel.2. Agrees to assume all cost of the care and transportation listed above.Rules and Safety. The Participant/Parent affirms that he or she agrees:1. To report all injuries (even minor injuries) so that SPORTS ACADEMY may make a record of the injury.2. To wear all recommended safety gear during participation.3. To follow all rules of the Activities at SPORTS ACADEMY.4. To inform SPORTS ACADEMY of any conduct or condition that creates a hazard for participants or others – and will immediately discontinue further participation in Activities until the hazardous conduct or condition is remedied or abated and no longer presents a hazard.5. That SPORTS ACADEMY has authority to halt my participation if it endangers the Participant or others.I, the PARTICIPANT/PARENT confirm that:1) This agreement supersedes any and all previous oral or written promises or agreements. I understand that this is the entire agreement between me and SPORTS ACADEMY and that it cannot be modified or changed in any way by representations or statements by any agent or employee of SPORTS ACADEMY.2) The foregoing Waiver of Liability and Release of Claims Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.3) If legal action is brought, the appropriate trial court for the County of Ventura in the State of California has the sole and exclusive jurisdiction and that only the substantive laws of the State of California shall apply.4) I will engage in good faith efforts to mediate any dispute that might arise. Any agreement reached will be formalized by a written contractual agreement at that time. Should the issue not be resolved by mediation, I agree that all disputes, controversies, or claims arising out of participation in SPORTS ACADEMY Activities shall be submitted to binding arbitration in accordance with the applicable rules of the American Arbitration Association then in effect.The undersigned acknowledges that he/she has read and understands the foregoing, has been informed of the risks faced by the Participant as a result of Participant's participation in and attendance at the Activities and has voluntarily signed this Waiver of Liability & Release of Claims with full knowledge of the legal consequences of doing so. If Parent is signing this Waiver of Liability & Release of Claims, he/she represents and warrants that he/she has explained the risks of the Activities to the Participant and that Participant understand said risks and this agreement.THIS WAIVER OF LIABILITY & RELEASE OF CLAIMS IS VALID INDEFINITELY UNLESS EXPRESSLY REVOKED IN WRITING, EXCEPT FOR THOSE PROVISIONS THAT ARE EXPRESSLY IRREVOCABLE.
*
Submit
Should be Empty: