Waiver & Release of Liability Form

FILM TO FIELD, LLC
WAIVER AND RELEASE OF LIABILITY FORM

Please fill out the secure online waiver and release of liability form for each athlete. If the player is under 18-years old, must be signed by the player’s parent or legal guardian. No player will be allowed to participate in Film to Field activities without this form, properly executed, and on file. If you have any questions, please feel free to contact us at filmtofield@gmail.com.

Athlete Information

Athlete's Name*

First NameLast Name

Position*

Grade*

Athlete's Age*

Current School Attending*

Future High School Attending*

Address*

Street Address

Street Address Line 2

CityState / Province

T-Shirt Size*

Shorts Size*

Parent/Guardian Information

Full Name*

First NameLast Name

Home Number

Area CodePhone Number

Cell Number*

Area CodePhone Number

E-mail*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the athlete have any allergies, chronic illness, or medical conditions that would limit high level activtiy?*

YesNo

Please describe.*

Is the athlete prescribed an inhaler? If yes, please explain any instructions.*

YesNo

Please explain any instructions.*

Informed Consent and Acknowledgement

I, the undersigned, in consideration for my participation in Film To Field, LLC training, do hereby willfully acknowledge that my signature below attests to my understanding and agreement that:

Football is a physical, contact, sport that involves the risk of injury. I assume all risks and hazards associated with my participation in the sport. I am in proper physical condition to participate in these trainings and have no illness, disease or existing injury or physical defect that would be aggravated by my participation. I will inform Brad Roach if this status changes. I further acknowledge that this risk may involve loss or damage to me or my property, including the risk of death, or other unforeseen consequences, including those which may be due to:

· the unavailability of immediate emergency medical care

· weather (e.g., rain, sleet or snow etc.)

· a defect in the equipment

· training methods employed by Brad Roach or his staff

Film To Field, LLC does not have personal injury insurance that covers my participation. Therefore, I should have a current, active, personal injury insurance policy in force, which covers my participation. Under any condition, I am responsible for any and all medical expenses arising from my participation, both in training and while travelling to and from these trainings/events. I have the right and responsibility to inspect the equipment and facilities prior to trainings/events and, if I believe that anything may be unsafe, I will advise any Film To Field staff of the condition and may refuse to participate. Participation assumes consent.

I authorize my photograph, picture or likeness, and voice to appear in any documentary, promotion (including advertising), television, video, or radio coverage of the trainings/events, without compensation.

I hereby release, waive liability, discharge, hold harmless, agree to indemnify, and covenant not to sue, Film To Field, LLC or any Film To Field, LLC staff, from any and all liability incurred in the conduct of, and my participation in, his training programs. This includes owners, lessors, and lessees of premises, municipalities, government agencies, successors, heirs, and assigns. I acknowledge it is my right and responsibility as a participant to refuse participation under any training methods.

I hereby state that I have carefully read the above waiver. Acceptance and understanding of this agreement are hereby acknowledged.

I have read and agree to the Informed Consent and Acknowledgement.

Please initial*

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Film To Field staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates of the registered sessions.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

I have read and agree to the Medical Release and Authorization.

Please initial*

Covid-19 Waiver

Waiver of Liability Relating to Coronavirus/COVID-19 The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be extremely contagious. The state of medical knowledge is evolving, but the virus is believed to spread from person-to-person contact and/or by contact with contaminated surfaces and objects, and even possibly in the air. People reportedly can be infected and show no symptoms and therefore spread the disease. The exact methods of spread and contraction are unknown, and there is no known treatment, cure, or vaccine for COVID-19. Evidence has shown that COVID-19 can cause serious and potentially life threatening illness and even death. Film To Field cannot prevent you [or your child(ren)] from becoming exposed to, contracting, or spreading COVID-19 while utilizing Film To Field's services or premises. It is not possible to prevent against the presence of the disease. Therefore, if you choose to utilize Film To Field and/or enter onto Film To Field's premises you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19. ASSUMPTION OF RISK: I have read and understood the above warning concerning COVID-19. I hereby choose to accept the risk of contracting COVID-19 for myself and/or my children in order to utilize [Film To Field]’s services and enter [Film To Field]’s premises. These services are of such value to me [and/or to my children,] that I accept the risk of being exposed to, contracting, and/or spreading COVID-19 in order to utilize [Film To Field]’s services and premises in person [if applicable: “rather than arranging for an alternative method of enjoying the same services virtually (e.g. videoconference)]. WAIVER OF LAWSUIT/LIABILITY: I hereby forever release and waive my right to bring suit against [Film To Field] and its owners, officers, directors, managers, officials, trustees, agents, employees, or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to utilizing [Film To Field]’s services and premises. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen.

I have read and agree to the Covid-19 Waiver.

Please initial*

Confirmation

By entering the information below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original manual paper signature.

Parent/Guardian/Participant Full Name*

First NameLast Name

Parent/Guardian/Participant Signature*

Confirmation E-mail*

After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at filmtofield@gmail.com.