Communicable Diseases and COVID Waiver

Name*

First NameMiddle NameLast Name

Date of Birth*

Date

I am UNDER age 18*

YesNo

Gender:*

MaleFemaleOther Gender Identity

Primary Role with SOMO:*

Team/Agency Name

Please include Agency Code if you know it. Ex: 66.099

Area Program:*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

E-mail*

Cellular Number*

Home Number

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

Participant Signature (required for participant adult(age18+) participants, including adult athletes with capacity to sign documents)

By signing this, I acknowledge that I have completely read and fully understand the information in this form.

Signature*

Signature Date*

Date

Parent/Guardian Signature(required for participant who is a minor(younger than age 18) or lacks capacity to sign documents.

This is to certify that I, as parent/guardian, with legal responsibility for this participant, have read and explained the provisions in this waiver/release to my child/ward including the risks of presence and participation and his/her personal responsibilities for adhering to the rules and regulations for protection against communicable diseases. Furthermore, my child/ward understands and accepts these risks and responsibilities. I for myself, my spouse, and child/ward do consent and agree to his/her release provided above for all the Releasees and myself, my spouse, and child/ward do release and agree to indemnify and hold harmless the Releasees for any and all liabilities incident to my minor child’s/ward’s presence or participation in these activities as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent provided by law.

Parent/Guardian Name*

First NameMiddle NameLast Name

Signature*

Parent Signature Date*

Date

Communicable Diseases and COVID-19 Waiver and Release