I represent that my child is in good physical condition and has no disability, impairment or ailment preventing use of F.C. Putnam’s facilities or participation in its programs.
I appreciate the danger of physical stress, strain and injury and I hereby assume whatever risk is involved and give my consent for my child to participate in F.C. Putnam’s programs including use of its facilities.
I hereby hold F.C. Putnam, its shareholders, affiliates, employees and representatives harmless from any and all claims, injuries, damages, and liabilities sustained or incurred in connection with my child’s participation in any F.C Putnam activity or use of its facilities.
I understand that F.C. Putnam retains the right to use any photographs, video-tapes, motion picture recording or any other record of the event for publicity, advertising or any legitimate purpose.
Once a player has registered they are obligated for the session. No refunds will be given EXCEPT in the instance of medical reasons. Requests for medical necessity refund should be submitted in writing from the doctor to:
Youth Concussion Waiver
It is the policy of F.C. Putnam Sports Inc. that children cannot participate in activities until this form has been signed, or completed on-line with our Organization. By consenting to this form, you acknowledge that you have received the fact sheet on concussions.
What is a Concussion: It is a type of brain injury caused by trauma. It can be caused by a hard bump or blow to or around the head, which causes the brain to move quickly inside the skull. You do not have to lose consciousness to have a concussion. If a concussion is not properly treated, it can make symptoms last longer and delay recovery. A second head trauma before recovery could lead to more serious injuries.
What are the signs and symptoms: There are many signs and symptoms linked with concussions. Your child may not have any symptoms until a few days after the injury. Signs are conditions observed by other people and symptoms are feelings reported by the athlete.
Signs observed by others:
- Appears dazed or stunned
- Moves Clumsily
- Forgets Plays.
- Answers questions slowly
- Is unsure of game or opponent
- Shows behavior or personality changes
- Symptoms reported by athletes:
- Headache Fuzzy Vision
- Nausea Feeling foggy
- Dizziness Concentration problems
What should you do if you suspect a concussion?
- Do not let your child play with a head injury.
- Check on your child often after the injury for new or worsening signs or symptoms. If the symptoms are getting worse, take them to the nearest emergency department.
- Take your child to the doctor for any symptoms of a concussion.
- Do not give your child pain medications without talking to your child’s doctor.
- Your child should stop all athletic activity until the doctor says it’s OK. Your child must stay out of play until they are cleared by a licensed healthcare provider. They must also bring a release form that the healthcare provider clears them.
- Educate your child on concussions and why he/she cannot play until the symptoms are gone.
- Tell your child’s coaches, school nurse and teachers if he/she has a concussion.
- In case of an urgent concern or emergency, call 911 or go to the nearest emergency department right away.
Call your child’s doctor right away if there are new signs that the doctor does not know about such as:
- Continued Vomiting
Existing Signs that get worse
Trouble knowing people or places
- Headaches that get worse Slurred speech
Loss of Consciousness Neck Pain
- Blood or fluid from nose or ear
- Tiredness or is hard to wake
- A large bump or bruise on scalp
This is general information and not specific medical advice. Always consult with a doctor or healthcare provider if you have questions or concerns about the health of a child.
Waiver of Liability Relating to Coronavirus/COVID-19
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health
Organization. COVID-19 is reported to be extremely contagious. The state of medical knowledge is
evolving, but the virus is believed to spread from person-to-person contact and/or by contact with
contaminated surfaces and objects, and even possibly in the air. People reportedly can be infected and
show no symptoms and therefore spread the disease. The exact methods of spread and contraction are
unknown, and there is no known treatment, cure, or vaccine for COVID-19. Evidence has shown that
COVID-19 can cause serious and potentially life threatening illness and even death .
FC Putnam Sports Inc. cannot prevent you [or your child(ren)] from becoming exposed to, contracting, or
spreading COVID-19 while utilizing FC Putnam Sports Inc.’s services or premises. It is not possible to
prevent the presence of the disease. Therefore, if you choose to utilize FC Putnam Sports Inc.’s services
and/or enter onto [name of company]’s premises you may be exposing yourself to and/or increasing your
risk of contracting or spreading COVID-19.
ASSUMPTION OF RISK: I have read and understood the above warning concerning COVID-19. I hereby
choose to accept the risk of contracting COVID-19 for myself and/or my children in order to utilize FC
Putnam Sports Inc.’s services and enter FC Putnam Sports Inc.’s premises. These services are of such
value to me [and/or to my children,] that I accept the risk of being exposed to, contracting, and/or
spreading COVID-19 in order to utilize FC Putnam Sports Inc.’s services and premises in person.
WAIVER OF LAWSUIT/LIABILITY: I hereby forever release and waive my right to bring suit against FC
Putnam Sports Inc. and its owners, officers, directors, managers, officials, trustees, agents, employees, or
other representatives in connection with exposure, infection, and/or spread of COVID-19 related to
utilizing FC Putnam Sports Inc.’s services and premises. I understand that this waiver means I give up my
right to bring any claims including for personal injuries, death, disease or property losses, or any other
loss, including but not limited to claims of negligence and give up any claim I may have to seek damages,
whether known or unknown, foreseen or unforeseen.
CHOICE OF LAW: I understand and agree that the law of the State of New York will apply to this contract.
I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND
FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING LIABILITY
AS DESCRIBED ABOVE.