ASSUMPTION OF RISK AND RELEASE I,___________________________ parent/legal guardian of____________________________, (name) (eventer name) acknowledge that as a Parent/legal Guardian. I authorize my child to participate in the Sports & Fitness Family Fun Day which is being organized by Sport-Specific Training Inc. I recognize that there are direct and inherent risks and hazards associated with this event, making it a dangerous activity with the potential to cause injury or loss of limb or life. With full knowledge of these facts and circumstances related to this event, I knowingly and voluntarily have elected and agreed to allow my child to undertake this activity, and I agree to assume all responsibility and risk from my child participation in this event, including, without limitation, all risk of injury or loss of limb or life, property damage and injury to others. I represent to officials of all organizers of the event that I have adequate health insurance necessary to provide for and pay any medical costs that may directly or indirectly result from my child(s) participation in this event, and I hereby release SSTI, Indialantic Youth Soccer Club and Brevard County Public Parks from any liability for such costs. I further represent to SSTI, IYSA, and Event organizers that my child has no health-related reason, condition or problem which would preclude or restrict him/her participation in this event. I understand that SSTI willingness to allow my child to participate in this Activity stems from these representations. As stated in the Emergency Contract and Medical Information Form below, I authorize SSTI and any of its officers, agents and employees to secure any and all necessary emergency medical treatment for my child in the event he or she suffer injury or illness while participating in this event. As a parent or legal guardian, I state that I am freely agreeing to assume and take on for myself all of the risks and responsibilities in any way associated with this event. In consideration of SSTI providing my child and I the opportunity to participate in this event; 1. I release SSTI and its trustees, officers, employees and agents from any and all liability, claims and actions that may arise from injury or harm to my child, from his/her death or from damage to his/her property in connection with this event, and I understand that this Release covers liability, claims and actions caused entirely or in part by any acts or failure to act of SSTI or its trustees, officers, employees or agents, including, without limitation, negligence, mistake or failure to supervise by SSTI 2. I agree to indemnify, defend and hold harmless SSTI and its trustees, officers, employees and agents from any liability, claim or action to a third party caused by child act or omission. I recognize that this Release means I am giving up, among other things, my rights to sue SSTI and its trustees, officers, employees and agents for injuries, damages, or losses that my child and/or I may incur. I also understand that this Release binds my heirs, executors, administrators, and assigns, as well as me. I acknowledge that I have had the chance to seek any third-party advice that I wish, including consulting legal counsel, prior to executing this Assumption of Risk and Release. 3. As a Parent/Coach participating in this Sports & Fitness Family Fun Day organized by SSTI, I agree to indemnify, defend and hold harmless SSTI and its trustees, officers, employees and agents from any liability, claim or action to a third party caused by my act or omission. I release SSTI and its trustees, officers, employees and agents from any and all liability, claims and actions that may arise from injury or harm to me or my child, from death or from damage to any of our property in connection with this event, and I understand that this Release covers liability, claims and actions caused entirely or in part by any acts or failure to act of SSTI or its trustees, officers, employees or agents, including, without limitation, negligence, mistake or failure to supervise by SSTI. I UNDERSTAND THAT THIS IS A RELEASE OF MY RIGHTS. I ATTEST THAT I HAVE READ ALL OF THIS RELEASE UNDERSTAND IT AND AGREE TO BE BOUND BY IT. ____________________________________ Date:__________________ (Releaser’s Signature) EMERGENCY CONTACT AND MEDICAL INFORMATION FORM As stated in the Assumption of Risk and Release above, I have authorized SSTI and any of its officers, employees and agents to secure any and all necessary emergency medical treatment for my child in the event that he/she suffer injury or illness while participating in the event. In furtherance of this request, I provide the following information, which I represent is accurate and may be relied upon, without further investigation, by any of the foregoing parties seeking to secure my child medical assistance: EMERGENCY CONTACT INFORMATION: Student Name:________________________________________________________________________ Name of Emergency Contact:____________________________________________________________ Relationship of Emergency Contact:______________________________________________________ Phone Number of Emergency Contact:____________________________________________________ HEALTH INSURANCE: Name of Health Insurance Company:______________________________________________________ Name of Policy Holder:________________________________________________________________ Policy Number:_______________________________________________________________________ MEDICAL HEALTH: Current Medication You are Taking:______________________________________________________ ________________________________________________________________________________________________________________________________________________________________________ Medical Conditions Emergency Assistance should be aware of:_________________________________ ________________________________________________________________________________________________________________________________________________________________________ I confirm that I freely and knowing authorize SSTI to use any and all of the information that I am providing herein, including, but not limited to medical-related information, in whatever manner SSTI deems necessary to render assistance to my child in the event of medical emergency. I have read this statement; I fully understand it; and I agree to be legally bound by it. Signature:______________________________________ Date:_________________