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Student full name: __________________________________________________________Phone: ______________________Emergency contact name: ______________________________________________________________ Relationship: ________________________________________________Phone: _________________Emergency contact name: ______________________________________________________________ Relationship: ________________________________________________Phone: _________________By signing your name in the spaces provided on the following documents, you agree your signature is the legal on this Agreement. By signing your name in the signature spaces provided on the following documents, you consent to be legally bound by this Agreement's terms and conditions.29493541102719___________Date00___________Date I Accept, being the Athlete of an Adult Age or Parent/Guardian of said Athlete of Minor Age, the above statement. ?Clearance and Waivers??Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19: By signing this agreement, I voluntarily assume the risk that members of my family may be exposed to COVID-19 by attending the voluntary workouts held at CCSD facilities. I understand that the risk of becoming exposed to or infected by COVID-19 at CCSD facilities may result from the actions, omissions, or negligence of myself, my child, and others, including, but not limited to, CCSD employees, trainers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury or illness to members of my family or myself including, but not limited to, personal injury, disability, and death. I have read the CCSD Infectious Disease plan and will not hold CCSD liable for any illness, damage, loss, claim, liability, or expense, of any kind, that I or my family members may experience or incur in connection with our attendance at CCSD facilities or participation in athletic workouts. On my behalf, and on behalf of my family, I hereby release, covenant not to sue, discharge, and hold harmless the CCSD, its employees, agents, and representatives, of and from the voluntary workouts, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of the CCSD, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any CCSD program4863852388648___________Date00___________Date.? ? ? ? The Dangers of Concussion: I have read and I am aware of the Dangers of Concussion.? This signature will represent myself and/or my child in relation to this understanding. 4817883372689___________Date00___________Date Sudden Cardiac Arrest: ? ?? I have read and I am aware of the Signs and Symptoms of Cardiac Arrest.? This signature will represent myself and/or my child in relation to this understanding. 4817883372689___________Date00___________Date Exercise in Heat and Humidity: have read the GHSA Practice Policy for Exercise in Heat and Humidity, and I am aware of the risks of participation. This signature will represent myself and/or my child in relation to this understanding. 4817883372689___________Date00___________Date Parental Consent For Athletic Participation:?Although participation in supervised interscholastic athletics may be one of the least hazardous activities in which students will engage in or out of school, by its nature, participation in interscholastic athletics includes a risk or injury which may range in severity from minor to long term catastrophic, including permanent paralysis from the neck down or death. Although serious injuries are not common in supervised school athletic programs, it is possible only to minimize, not eliminate the risk.? Participants can and have the responsibility to help reduce the chance of injury. Players must obey all safety rules, report all physical problems to their coaches, follow a proper conditioning program, and inspect their equipment daily.? By signing this permission form, you acknowledge that you have read and understand this warning, and you give consent for your child to compete in athletics at Clarke County High Schools in Georgia High School Association approved sports and to accompany any school team of which the student is a member on any of its local or out-of-town trips.? Parents or students who do not wish to accept the risks described in this warning should not sign this permission form.?4817883372689___________Date00___________Date Adequate Insurance Waiver: My son/daughter is adequately and currently covered by accident insurance that will cover injuries sustained while participating in interscholastic athletics and the policy is submitted to the Dragonfly Demographics Section.?4817883372689___________Date00___________Date Consent to Provide Care: I, _______________________________(parent/guardian), the parent or guardian of __________________________________________("the student athlete"), hereby authorize the physician(s), athletic trainer(s) and/or sports medicine staff representing Piedmont Healthcare to evaluate, treat, and rehabilitate athletic related injuries for the student-athlete.? The Sports Medicine Staff may gather and release information regarding the student-athlete's protected health and participation in athletics in Clarke County High Schools.? I/We further authorize the physician(s), athletic trainer(s), and/or sports medicine staff representing Piedmont Healthcare to inquire on and receive the student-athlete's protected health information from other medical personnel as it relates to his/her care by the sports medicine staff at Piedmont Healthcare.4817883372689___________Date00___________Date This signature certifies that I have read the above statements and that I agree with school policies and procedures.? I certify that the above information is correct.4817883372689___________Date00___________Date ................
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