INFORMED CONSENT AND ACKNOWLEDGEMENT AGREEMENT
Cadwallader Middle School
2015 DanceCamp
Head Coach: ToiChalker
WARNING!
Dancing can be a vigorous, physical activity involving motion, rotation and height in a unique environment and as such carries with it a higher than ordinary risk of injury. Be advised that serious, catastrophic injury, paralysis or even death could occur particularly if a participant were to land on her head, neck or back!
I/We, ______, parents and/or legal guardians of ______, who is a student at ______School wishes to participate in their dance program, voluntarily give our consent for such participation by our daughter.
It has been adequately explained to us that dance is an activity which may involve airborne inversion of the body and therefore there is an increased potential that any one of the routines involving our daughter’s participation could lead to serious injury, paralysis or even death.
We understand that out daughter is required to be in good physical shape and condition and that the activities in which she will be asked to participate are strenuous and require physical and athletic agility. It has been fully explained to us that these activities include, but are not necessarily limited to a variety of gymnastic maneuvers, including somersaults, back handsprings and aerials; that there will be a variety of mounts, tosses, and stunts requiring the coordination of more than one participant on the team; and that these activities will not be confined to any one site or venue, but rather will involve a variety of sites or venues throughout the year.
We represent to you that, to the best of our knowledge and belief, our daughter has no physical medical or mental disability or other limitation that would restrict her ability to fully participate in this activity. We have been informed that our daughter must be examined by a physician prior to participation in these activities and we agree to such examination. We will arrange for a physical examination of our daughter by a qualified and licensed medical physician to qualify her a participant in this activity. We further agree to immediately notify the appropriate school personnel in the event of any change in our daughter’s health status.
We agree to, and by signing this agreement, release the coaches, advisors, volunteers and staff of Cadwallader Middle School and the Board of Education from any claim of negligence by ourselves, our daughter, our heirs, executors and assigns, from any liability arising from claims or damages for injury to our daughter and any claims for loss of or damages to her property which may arise out of her participation in this school sponsored program for the 2015 - 2016 cheerleading year.
In witness whereof, I/we have affixed our signature(s) to this agreement this ______day of ______, 2015 at Cadwallader Middle School, gym.
______/______/______
(Parent’s and/or legal guardian’s signature)(Date)
WARNING OF RISK
SERIOUS, CATASTROPHIC AND PERHAPS FATAL INJURY
MAY RESULT FROM ATHLETIC PARTICIPAITON.
By its very nature, competitive athletics may put student athletes (dancers) in situations in which accidents may occur. Athletic competition can result in accidents, strenuous physical exertion, and numerous other exposures to risk injury.
Students and Parents must understand and assess the risks involved in such participation and make their choice to participate in spite of those risks. The obligation of parents and students in making this choice to participate cannot be overstated. There have been accidents resulting in death, paraplegia, quadriplegia and other serious permanent physical impairment as a result of athletic competition.
Cadwallader Middle School athletes will be instructed in proper techniques to be used in athletic competition and in the proper utilization of all equipment worn or used in practice and competition. Student/Athletes must adhere to that instruction and utilization and must refrain from improper uses and techniques.
However, no amount of instruction, precaution, and supervision will totally eliminate all risk of serious, catastrophic, or even fatal injury. By granting permission for your Child/Athlete to participate in athletic competition, you, the parent or guardian, acknowledge such risk exists. By choosing to participate, you, the student/athlete, acknowledge that such risk exists.
If any of the foregoing is not completely understood, please contact the coaches or school administration.
Student Signature: ______Parent Signature: ______
Date: ______Date: ______
Parent/Guardian Name: ______
Address: ______
Home Phone Number: ______Parent Cell/Work Number: ______
Emergency Contact: ______Number: ______
Medical:
Please list below any medical situations the coach should be aware of:
______
Medical Aid Provision:
We do hereby give permission for the dance coach/school administrators to secure whatever emergency medical treatment my child needs at any time during practice or try-outs.
______Date: ______
(Signature of Parent/Guardian)