Optimist Club of Herndon

Statement of Policy

  1. Policy Name: Accident and Liability Insurance
  1. Policy Effective Date:July8, 2014
  1. Policy Review Date (or “None”): Annually
  1. Policy Expiration Date (or “None”): None
  1. Policy Purpose/Objectives:

The purpose of this policy is to ensure that the Optimist Club of Herndon (hereafter referred to as “HOC”) and eachof its programs implements and maintains sufficient accident and liability insurance coverage and associated participant waivers and risk/hazard awareness programs.

  1. Persons/Programs to Which the Policy Applies:
  1. This policy applies to the HOC and all HOC programs.
  2. This policy applies to all HOCparticipants, includingHOCprogram managers, volunteers, game officials, and participants.
  1. Requirements to Satisfy the Policy:

This policy is satisfied by implementation of (a), (b),(c), and (d) below:

  1. Each HOC program maintains accident and liability insurance coverage
  2. using one or a combination of:
  3. The HOC-provided accident and liability insurance providers
  4. The youth program’s parent national or state program which provides manager, volunteer, game official, and participant accident insurance and a Certificate of Liability Insurance with “Optimist Club of Herndon VA” named as a Certificate Holder
  5. for a minimum of the following amounts:
  6. Accident
  7. Death/dismemberment per occurrence $10,000
  8. Aggregate per accident $250,000
  9. Medical expense excess $100,000
  10. Liability
  11. Each occurrence $1,000,000
  12. Damage to rented premises each occurrence $100,000
  13. Medical expense each person $5,000
  14. Personal injury $1,000,000
  15. General aggregate $3,000,000
  16. Automobile each accident $1,000,000
  17. covering all volunteers (not just coaches), game officials, and youth participants registered with the program and all activities scheduled/sponsored/supervised by the program, including games, practices, and other sanctioned events (e.g., fundraisers, team building events, parades)
  18. Each HOC program implements the HOC-provided Emergency Treatment/Medical Release/Liability Waiver agreements as part of itsmanager/volunteer/game official/participant registration(s).
  19. Each HOC program provides concussion awareness information as part of its manager/volunteer/game official/participant registration(s). The concussion awareness information can be provided within the Emergency Treatment/Medical Release/Liability Waiver agreementin lieu of including separate concussion awareness information acknowledgement within the registration form.
  20. The program maintains a record of accidents/injuries occurring during HOC program activities, including the identification of the person(s) involved in and witnessing the incident, the date and location of the incident, the specific action(s) that led to the accident/injury, a brief description of the injury, and what action(s) the program managers/volunteers/parents took at the time of and after the incident. Any accident/injury information collected is covered by the HOC Personally Identifiable Information (PII) Handling and Non-Disclosure Policy.

Each HOC program should consider providing, but is not required to provide, a manager/volunteer/game official/participant/parent concussion awareness training session using the “Heads Up: Concussion in Youth Sports” information provided by the U.S. Department of Health and Human Services (HHS) Center for Disease Control and Prevention (CDC). The“Heads Up”initiative provides important information on preventing, recognizing, and responding to a concussion. For more information, visit these Websites:

  1. Assistance/Resources Provided to Execute the Policy:
  1. The HOC will establish accident and liability insurance providers for use by HOC programs.
  2. The HOC will provide standard language forEmergency Treatment/Medical Release/Liability Waiveragreements and concussion awareness informationto be integrated into manager/volunteer/game official/participantregistration forms implemented in the HOC’s program registration/management system.
  3. A member of theHOCBoard of Directors, or another HOC program’s representative, will be made available to provide training and assistance on how to implement the Emergency Treatment/Medical Release/Liability Waiver agreements and concussion awareness information in the HOC’s program registration/management system.
  1. Policy Implementation:
  1. Before any registration opens for an HOC program, evidence of accident and liability coverage must be made available to the HOC Board of Directors.
  2. By October 1, 2014, all HOC programs must have Emergency Treatment/Medical Release/Liability Waiver agreements and concussion awareness information included in their manager/volunteer/game official/participant registration forms.
  1. Consequences of Failure to Follow the Policy:
  1. If a HOC program is found to not be in compliance with this policy, the HOC Board of Directors will send a memo to the Commissioner, President, and/or program board/management committee identifying the problem, the corrective action(s) to be taken, and the timeframe for executing the corrective action.
  2. If the program Commissioner, President, and/or program board/management committee does not execute the corrective action within the specified timeframe, the HOC Board of Directors will suspend access of all of the program’s registration/management system managers until a meeting with the HOC Board of Directors takes place and corrective actions are taken.

Optimist Club of Herndon Emergency Treatment/Medical Release/Liability Waiver Agreement – Minor Participant

I, the undersigned parent or legal guardian of the above-named participant, a minor, grant my permission for this minor to participate in all of the <insert HOC program name and acronym> program activities, including transportation. I do hereby authorize the managers, volunteers, or parents of team members acting in the capacity of activity supervisors/vehicle drivers, as Agents for the undersigned, to consent to emergency medical, surgical or dental examination, treatment, etc., until a parent or legal guardian can be contacted. I will not hold these persons legally or financially responsible in any way. I also acknowledge that various private and public landowners (Owners) have agreed to allow <insert HOCprogram acronym> to use certain real property owned by the Owners (the property) for its activities, that Owners will not be providing any supervisory personnel or other services for such activities or the property, and that Owners shall have no responsibility for supervision, maintenance, or repair of the property. In addition, the undersigned fully understands the risks and hazards inherent in participating in physical activities, agrees to assume the risk of injury and harm, and further agrees to release and waive all claims against <insert HOC program acronym>, Optimist Club of Herndon VA, Owners, Agents, sponsors, volunteers, or other program participants for any injury, harm, or other damage that may occur.

To help ensure the health and safety of young athletes, the U.S. Department of Health and Human Services (HHS) Center for Disease Control and Prevention (CDC) developed the“Heads Up: Concussion in Youth Sports”initiative to offer information about concussions to coaches, parents, and athletes involved in youth sports. The“Heads Up”initiative provides important information on preventing, recognizing, and responding to a concussion. For more information, please visit these Websites:

Prompt: I, on my own behalf and on behalf of all the other parents/guardians of the participant, accept the above

Optimist Club of Herndon Emergency Treatment/Medical Release/Liability Waiver Agreement – Adult Participant

I do hereby authorize the <insert HOC program name and acronym>managers, volunteers, or parents of team members acting in the capacity of activity supervisors/vehicle drivers, as Agents for the undersigned, to consent to emergency medical, surgical or dental examination, treatment, etc. on my behalf. I will not hold these persons legally or financially responsible in any way. I also acknowledge that various private and public landowners (Owners) have agreed to allow <insert HOC program acronym> to use certain real property owned by the Owners (the property) for its activities, that Owners will not be providing any supervisory personnel or other services for such activities or the property, and that Owners shall have no responsibility for supervision, maintenance, or repair of the property. In addition, the undersigned fully understands the risks and hazards inherent in participating in physical activities, agrees to assume the risk of injury and harm, and further agrees to release and waive all claims against <insert HOC program acronym>, Optimist Club of Herndon VA, Owners, Agents, sponsors, volunteers, or other program participants for any injury, harm, or other damage that may occur.

To help ensure the health and safety of young athletes, the U.S. Department of Health and Human Services (HHS) Center for Disease Control and Prevention (CDC) developed the“Heads Up: Concussion in Youth Sports”initiative to offer information about concussions to coaches, parents, and athletes involved in youth sports. The“Heads Up”initiative provides important information on preventing, recognizing, and responding to a concussion. For more information, please visit these Websites:

Prompt: I accept the above

HOC Policy – Accident and Liability Insurance v6Page 1 of 5