AFTER-SCHOOL ALL-STARS HAWAII WAIʻANAE REGISTRATION FORM

An emailed copy of this completed registration form will be sent to the Site Coordinator to register your student. You will receive a call or email to confirm that your student’s registration has been received.

Parent/Guardian 1 (will be contacted 1st in the case of an emergency and will be added to our Emergency Call and Reminder System)

Parent/Guardian 2

YOU WILL BE REDIRECTED AUTOMATICALLY TO A SECOND FORM TO INDICATE THE INDIVIDUALS AUTHORIZED TO PICK-UP YOUR STUDENT UPON SUBMISSION OF THE REGISTRATION FORM

 

PLEASE NOTE IF YOU CHOOSE THE PICK UP OPTION, YOUR CHILD MUST BE PICKED UP PROMPTLY AT THE END OF PROGRAM AND MAY NOT BE RELEASED VIA PHONE

AS AN ORGANIZATION DEDICATED TO MENTORING AND MOLDING THE CHARACTER OF YOUNG PEOPLE, WE PLACE A SPECIAL EMPHASIS ON SELF-RESPECT AND RESPECTING OTHERS. WE BELIEVE IT IS OF THE UTMOST IMPORTANCE THAT YOU AS PARENTS/GUARDIANS ARE AWARE OF THE DISCIPLINE POLICIES AND PROCEDURES THAT HELP MAINTAIN A CULTURE OF RESPECT AND INTEGRITY. YOU MAY OBTAIN A COPY OF THE ASAS DISCIPLINE POLICIES, BY REQUEST, FROM THE ASAS SITE COORDINATOR.

I understand and support ASAS procedures as they pertain to student behavior, safety and conduct

I understand that attendance at ASAS programs is voluntary

I understand that it is my child’s responsibility to attend program

Parent liability/Parent authorization:

being allowed to participate in the After-School All-Stars (ASAS) Program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:

1. I certify that the above participant is in good physical and mental health and has never been declared medically ineligible from athletic competition. I further certify that the above mentioned participant has had no pre-existing medical condition or injury, listed as, but not limited to: exercise-induced asthma, cardiac or pulmonary (lung) disease, abnormal organ deficiencies, and head or neck injuries which may limit playing abilities; and,

2. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis, and death, and while particular skills, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist; and,

3. FOR MYSELF, SPOUSE AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FORM THE NEGLIGENCE OF THE RELEASEES OR OTHERS, AND ASSUME FULL RESPONISIBLITY FOR MY CHILD’S PARTICIPATION; and,

4. I willingly agree to comply with the program’s stated and customary terms and conditions for my child’s participation. If however, I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from participation and bring such to the attention of the nearest official immediately; and,

5. I, for myself and of behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMIFY AND HOLD HARMLESS ASAS, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners, and leasers of premises used for the activity (“RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABLITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Consent for treatment:

I understand that in case of emergencies, ASAS will make every effort to contact the parent(s)/guardian(s) before any treatment is given. In the event that we cannot be contacted, I hereby authorize the physician or hospital selected by ASAS to hospitalize, secure treatment for and to order injection, anesthesia, or surgery for my child. It is further understood that I (the parent/guardian) will assume full responsibility for any such treatment, including the payment of all costs and transportation and will hold the ASAS Site Coordinator, After School Staff and Youth Leaders, harmless there from.

I understand that it is my responsibility to review and complete the Brain Space Training Course resources provided by the Hawaii Concussion Awareness Management Program (HCAMP) and recommended by After-School All-Stars Hawaii (ASAS). I agree to support After-School All-Stars Hawaii in holding strict standards with regard to concussion management as per the standards established in the Hawaii Concussion Law Act 262.

Parental consent for photographs:

I hereby grant full permission to After-School All-Stars Hawaii to use my child’s photograph in videotapes, publications, motion pictures, recordings and all other events to be used solely for the purposes of After-School All-Stars Hawaii promotional material and publications, and waive any rights of compensation or ownership thereto.

Parental consent to access report cards and other school data:

I authorize the release of the following school information regarding my child to ASAS: (a) student identification number, (b) school attendance, (c)demographic data, including, but not limited to the participant’s race/ethnicity, whether the participant receives special education services, whether the participant is considered an English Language Learner and whether participant participates in the free or reduced priced lunch program, (d) achievement data, including but not limited, grades and standardized test scores, and (e) behavior data. Additionally, I understand that the information as noted above will only be shared with qualified professional staff from ASAS and with contracted third-party ASAS evaluators.

Consent for evaluation and/complete surveys:

I hereby give permission for my child and give consent for myself, as a parent or guardian, to participate in surveys and participate in evaluations that will be used to determine program effectiveness or to promote the program. I understand that my child’s and my answers to these surveys are strictly confidential.

Aloha After‐School All‐Stars Hawaii (ASAS) Parents and Guardians,

In order to provide your student athlete with the safest possible experience in our programs, ASAS practices strict adherence to concussion protocols. We see it as duty to inform students/parents/guardians of the risks associated with brain injuries as well as to provide information about an online training resource for you to stay informed about brain injuries, specifically concussions and the Hawaii Concussion Law.

• Education of parents, athletes, school staff and administrators and sports officials
• Includes youth sports from 11 years old and above.
• Annual training of coaches.
• Mandatory immediate removal of the athlete when a concussion is suspected.
• Need for clearance to return to play by a licensed health care provider trained in concussion management.
• Return to learn and gradual return to play protocols.

We would like to take this oppurtunity to inform you about an information resource and strongly suggest you take the time to become knowledgeable about brain injuries and concussion protocols.

Please find below a link to the Hawaii Concussion Awareness Management Program educational course for parents. You will find this resource helpful in ensureing you and your student-athlete make informed decisions about staying safe in relation to concussions and potential brain injuries.

On completion of the course you will receive a downloadable certificate.

https://hawaiiconcussion.com/info?module=500.1&role=6