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Emergency Contact Information
Secondary Emergency Contact Information
- This informatoin must be completed so incase orginal guardian is not abe to be contacted
Participant Medical Treatment Authorization, Release & Liability Waiver
THIS PLAYER MEDICAL TREATMENT AUTHORIZATION, RELEASE & LIABILITY WAIVER (THIS“WAIVER”) MUST BE COMPLETED AND EXECUTED BEFORE PARTICIPANT CAN PARTICIPATE INA CHICAGO FIRE FOOTBALL IN THE COMMUNITY PROGRAM (THE “CAMP”).In consideration of the below-listed participant (“Participant”) being given the opportunity toparticipate in the Camp, each of Participant and his or her parent/legal guardian herebyacknowledges, agrees and covenants as follows:No Remuneration or Insurance Coverage: Participant is participating in the Camp on avolunteer basis, solely in exchange for the opportunity to practice and play soccer and engagein related training and development activities. Participant will not receive any monetary orother remuneration in exchange for Participant’s participation in the Camp, is not an employeeof any of the Released Parties (as defined below) and is not covered by workers’ compensationinsurance or any other insurance policy held by any of the Released Parties.Physician Examination and Medical Treatment Authorization: Participant has received aphysical examination by a medical physician and has been found physically capable ofparticipating in the Camp. Each of Participant and his or her parent/legal guardian herebyauthorizes any coach, staff member, athletic trainer, team manager, Camp official and/oremergency medical technician, together with any doctor of medicine, nurse, dentist, medicaltreatment facility and/or associated personnel (each, a “Provider”) to provide Participant withmedical and dental assistance and/or treatment and agrees to be financially responsible for thecost of any such assistance and/or treatment. Each of Participant and his or her parent/legalguardian hereby authorizes emergency transportation of Participant to a medical treatmentfacility, should a Provider consider it to be warranted, and agrees to be financially responsiblefor the cost of such transportation.Authorization for Release of Protected Health Information: Each of Participant and his or herparent/legal guardian hereby authorizes any Provider who has protected health informationregarding Participant to release such information to any third party, including, but not limitedto, other medical providers and insurance companies, for purposes of treatment, paymentand/or other health care operations.Assumption of Risks: Each of Participant and his or her parent/legal guardian herebyacknowledges that Participant will be engaging in activities that involve risk of injury and thatthe Camp is for the sport of soccer and related activities, such as strength training, running andother aerobic activities. The Camp may or will involve strenuous exertions using various musclegroups, quick movements involving speed and change of direction, potential contact withsoccer balls, equipment, fixed objects (e.g., goals), other participants or referees (includingpersons that are older or younger and who may be larger or smaller in terms of weight andheight) and various surfaces types of various condition, and sustained physical activity thatplaces stress on the cardiovascular and nervous systems. Each of Participant and his or herparent/legal guardian hereby further acknowledges that the specific risks vary from one activityto another, but in each activity the risks range from (1) minor injuries, such as cuts, bruises, muscle strains and sprains, to (2) major injuries, such as broken or fractured bones, concussionor lost teeth, to (3) catastrophic injuries, such as heart attacks or fractured skull or those thatcause disfigurement, loss of mental capacity, loss of sight, speech or hearing, paralysis or death.In addition, each of Participant and his or her parent/legal guardian acknowledges that, byparticipating in the Camp, Participant may be exposed, or expose others, to contagious andpotentially harmful or deadly disease, such as influenza, common cold, chicken pox, meningitisor measles. Each of Participant and his or her parent/legal guardian acknowledges thatParticipant will also be exposed to (i) risks while traveling (including to and from the Camp), (ii)large crowds, and (iii) risks related to receipt of medical or dental examination or treatment forany physical or mental conditions as pre-authorized pursuant to this Waiver.Each of Participant and his or her parent/legal guardian has read the paragraph immediatelyabove and (1) understands the nature of the activities in the Camp, (2) understands thedemands of those activities relative to the physical condition and skill level of Participant and(3) acknowledges the types of injuries and illnesses, as well as risks related to medical or dentalexamination or treatment for any physical or medical condition, which may occur as a result ofparticipation in the Camp. Each of Participant and his or her parent/legal guardian asserts that(1) Participant’s participation in the Camp and use of the Camp’s facilities and/or services isvoluntary, (2) HE OR SHE WILLINGLY AND VOLUNTARILY ASSUMES ALL RISKS IN ANY WAYASSOCIATED WITH, RELATED TO, OR OCCURRING AS A RESULT OF, PARTICIPANT’SPARTICIPATION IN THE CAMP AND USE OF THE CAMP’S FACILITIES AND/OR SERVICES,HOWEVER CAUSED OR ARISING, and (3) he or she accepts personal responsibility following anyinjury, disability or death of Participant and, as such, understands that Chicago Fire FootballClub recommends that he or she should have insurance to cover Participant in the event ofinjury, disability or death while participating in the Camp.Release, Waiver and Indemnity: To the fullest extent permitted by law, each of Participant andhis or her parent/legal guardian hereby forever releases, waives, discharges, agrees toindemnify and hold harmless, and covenants not to sue Chicago Fire Football Club, LLC, TalmanSoccer, LLC, Chicago Fire Juniors City, Chicago Fire Juniors South, Chicago Fire Juniors West,Major League Soccer, L.L.C., Soccer United Marketing, LLC, Youth Elite Soccer LLC and each oftheir respective predecessors, successors, affiliates, members, managers, partners,shareholders, trustees, and controlling and controlled persons (together with any and alldirectors, officers, employees, volunteers, independent contractors, representatives, attorneys,agents and assignees of each of the foregoing) (collectively, the “Released Parties”) from andagainst any and all claims, actions, causes of action, demands, indemnity, suits, debts, sums,accounts, controversies, rights, damages, awards, costs, attorneys’ fees, losses, expenses andliabilities whatsoever (contingent, accrued, matured, direct, derivative, personal, individual,collective, assigned, discovered, undiscovered, known, unknown, inchoate or otherwise)(collectively, “Claims”) that such person (or his or her heirs or personal representatives) maynow have, acquire, own or hold, or at any time heretofore owned, acquired or held, or could ormay hereafter own, acquire or hold, against any Released Party in connection with, relating to,or arising out of Participant’s participation in the Camp (including, without limitation, use of anyfield or facility owned, leased or used by the Camp, or services related thereto) even, in eachcase, if the Claims that the undersigned is releasing arise out of the negligence or carelessness of one or more of the Released Parties (collectively, the “Released Claims”). The provisions ofthis paragraph are specifically intended to be binding on the personal representatives, heirs,legatees, beneficiaries, executors and assigns of each of Participant and his or herparent(s)/legal guardian(s). Each of Participant and his or her parent/legal guardian admits thepossibility that he or she and/or his or her successors may not fully know the number ormagnitude of all of the Released Claims, but nevertheless intends to assume all risks byreleasing such unknown claims, and agrees that this release is a full and final release and waiverof all of the Released Claims. Each of Participant and his or her parent/legal guardian expresslywaives the benefit of any statutory or other provision that creates any exception to theprovisions of this paragraph.Publicity Waiver and Consent: Each of Participant and his or her parent/legal guardian herebyconsents to any and all recording, photographing and filming of such person and agrees thateach of the Released Parties can use the photograph, quotations, name and likeness of suchperson, as well as any videotapes, motion pictures, recordings or other record of participationof such person in the Camp, at any time and in any manner, including to promote or advertisethe Camp, Chicago Fire Football In The Community or Chicago Fire Football Club, withoutpayment to, or additional consent of or notification to, such person.Severability and Venue: Each of Participant and his or her parent/legal guardian acknowledgesand agrees that this Waiver is intended to be as broad and inclusive as is permitted by the lawsof the State of Illinois and that if any portion hereof is held invalid, it is agreed that theremaining portion of this Waiver will continue in full force and effect.Acknowledgment of Rules and Standards of Conduct: Each of Participant and his or herparent/legal guardian acknowledges and understands that the Camp has rules and standards ofconduct that are set forth in the Camp’s Regulations and Disciplinary Code. Participant hasreviewed the Camp’s Regulations and Disciplinary Code, and each of Participant and his or herparent/legal guardian agrees that Participant will abide by the rules and standards set forth inthe Camp’s Regulations and Disciplinary Code. ATTORNEYS’ FEES & JURY WAIVER: IN THE EVENT THAT IT SHOULD BECOME NECESSARY FORCHICAGO FIRE FOOTBALL CLUB OR ANY RELEASED PARTY TO ENFORCE THE OBLIGATIONS OFPARTCIPANT OR HIS OR HER PARENT/LEGAL GUARADIAN HEREUNDER, OR TO DEFENDAGAINST ANY CLAIMS ASSERTED BY PARTICIPANT OR HIS OR HER PARENT/LEGAL GUARDIANARISING FROM OR RELATED TO THIS WAIVER, EACH OF PARTICIPANT AND HIS OR HERPARENT/LEGAL GUARDIAN ALSO AGREES TO AND SHALL PAY TO CHICAGO FIRE FOOTBALLCLUB OR SUCH RELEASED PARTY, ON DEMAND, ALL REASONABLE COSTS OF COLLECTION,ENFORCEMENT OR DEFENSE INCURRED BY CHICAGO FIRE FOOTBALL CLUB OR SUCHRELEASED PARTY, INCLUDING, WITHOUT LIMITATION, ATTORNEYS' FEES AND LEGALEXPENSES FOR THE SERVICES OF COUNSEL OF CHICAGO FIRE FOOTBALL CLUB OR SUCHRELEASED PARTY, WHETHER OR NOT SUIT BE BROUGHT. EACH OF PARTICIPANT AND HIS ORHER PARENT/LEGAL GUARDIAN, AFTER CONSULTING OR HAVING HAD THE OPPORTUNITY TOCONSULT WITH COUNSEL, HEREBY KNOWINGLY, VOLUNTARILY AND INTENTIONALLY WAIVESANY RIGHT HE OR SHE MAY HAVE TO A TRIAL BY JURY IN ANY LITIGATION BASED UPON ORARISING OUT OF THIS WAIVER, OR ANY COURSE OF CONDUCT, DEALING, STATEMENT(WHETHER ORAL OR WRITTEN), OR ACTIONS OF ANY OF THEM. NEITHER PARTICIPANT NORHIS OR HER PARENT/LEGAL GUARDIAN SHALL SEEK TO CONSOLIDATE, BY COUNTERCLAIM OROTHERWISE, ANY ACTION IN WHICH A JURY TRIAL HAS BEEN WAIVED WITH ANY OTHERACTION IN WHICH A JURY TRIAL CANNOT BE OR HAS NOT BEEN WAIVED. THESE PROVISIONSSHALL NOT BE DEEMED TO HAVE BEEN MODIFIED IN ANY RESPECT OR RELINQUISHED BY ANYOF CHICAGO FIRE FOOTBALL CLUB OR PARTCIPANT OR HIS OR HER PARENT/LEGALGUARDIAN EXCEPT BY A WRITTEN INSTRUMENT EXECUTED BY EACH OF CHICAGO FIREFOOTBALL CLUB AND PARTICIPANT AND HIS OR HER PARENT/LEGAL GUARDIAN.Assignment: This Waiver may not be assigned by Participant or his or her parent/legal guardianwithout the express written consent of Chicago Fire Football Club.Each of Participant and his or her parent/legal guardian has read this Waiver carefully and fullyunderstands its contents. By signing this Waiver, each of Participant and his or her parent/legalguardian acknowledges that he or she is consenting to Participant’s participation in the Campon the terms and conditions set forth herein. Each of Participant and his or her parent/legalguardian is aware that this is an agreement not to sue the Released Parties and constitutes acomplete release of liability by each of Participant and his or her parent/legal guardian, andanyone acting on behalf of Participant and/or his or her parent/legal guardian. Each ofParticipant and his or her parent/legal guardian acknowledges that he or she is signing thisWaiver of his or her own free will, with full knowledge of the risks being assumed by him or her.