Hold Harmless and Indemnity Agreement Slip and Fall - DOC by hcj61332

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									                                   Saratoga Rowing Association - PO Box 750
                                          Saratoga Springs NY 12866
                                              Registration 2009-2010
                     SECTION 1           ROWER INFORMATION                                         Print neatly please-fill out all fields

Name__________________________________________     M/F     Phone________________________
Mail Address_________________________________________________Zip_________Grad Year: 20____
School Name ____________________________________ ROWER EMAIL______________________________
PARENT/GUARDIAN INFORMATION                     Print neatly please-fill out all fields
Name:______________________________________    Name:___________________________________________
Address:____________________________________   Address(if different)________________________________
__________________________________________ _______________________________________________________
Phone(H):___________________________________   Phone(H-if different):_______________________________
Phone(Work/Cell):___________________________   Phone(Work/Cell):__________________________________
Email:______________________________________   Email:____________________________________________
Occupation:_________________________________   Occupation:_______________________________________
                     INFORMATION WILL BE USED FOR VOLUNTEER COMMITTEES AND SRA EMAIL OR MAILINGS
     Saratoga Rowing Association has a rower’s assistance program. If you would like an application, please call 587-6697
                        or email info@saratogarowing.com. Online at www.saratogarowing.com
     Mail should be sent to the address on top of this form or dropped off to 543 Union Ave-- Do not send mail to the
                                         Boathouse address as it will be returned.

 SECTION 2                                 AUTHORIZATION for medical treatment of minors
    If your child needs medical, dental, health or hospital services, under law, you as a parent must give permission. Naturally, if you are with
your child you can give permission as the need arises. You can prepare for those unexpected times when you are not with your child by filling
out this authorization form. Using this form, you can give permission to other adults to act for you, in you absence, regarding the treatment of
your child. This is a legal document. After you complete this form, give a copy to each adult you have named to act on your behalf. If your child
needs unexpected medical treatment, the responsible adult should present this document to the appropriate person -- physician, dentist, or
hospital representative.
    When a true emergency exists a child may be treated without parental consent. This will happen when a physician determines the child
needs immediate medical care and that an attempt to obtain parental consent would result in a delay which would increase the risk to the child’s
life or health.
PLEASE COMPLETE ALL SECTIONS
A.          IDENTIFICATION                                                        Social Security #_________________________________
Name of Minor ________________________ Date of Birth_____
B.          ALLERGIES                                                             If your child has allergies, indicate if your child    does or      does
My child has the following allergies or medical conditions (if                    not have an allergic reaction kit for any of the listed allergies. If
                                                                                  your child does, attach specific instructions to this form and
none, write NONE):__________________________________                              indicate whether the child or the coach/chaperone will keep the kit.
C.        MEDICATIONS, INCLUDING INHALERS
Medication                                                                  Dosage (amount and frequency)
    Prescription    Over-the-Counter
Name:
    Prescription    Over-the-Counter
Name:
    Prescription    Over-the-Counter
Name:
My child uses inhalers as described above for respiratory ailments, and
    does or      does not have my permission to keep this with him/her. If your child does not, then the coach/chaperone will keep it with him
or her.
D.         HEALTH CONDITIONS
Describe any health conditions or other health information that would help us treat your child in your absence:
_____________________________________________________________________________________________________________________
Emergency Contact Name other than listed below: __________________________ Contact Phone# _________________
Hospitalization Coverage for Above Named Minor (Please attach a copy of the front and back of your insurance card)
 Insurance Co. or Gov. Program ID/Contract#_______________________Name of Ins. Plan___________________________
Name of Primary Policy Holder____________________________                  Social Security of Primary Policy Holder__________
Physician’s Name ______________________________________                    Physician’s Phone#__________________________
Address______________________________________________
I, being the parent, custodian or legal guardian of the above named minor, do hereby appoint the Club Executive Director, a Head
Coach or each other Club Coach or designated parent chaperone as may be designated by the Executive Director from time to time
as responsible for supervising minor participants, to act on my behalf in authorizing unexpected medical, dental, surgical care and
hospitalization for the above named minor in my absence.
Printed Name________________________________________ Signature__________________________________________________
Date_________________________ Phone(H)________________Work)________________________ (Cell)_______________________
Street Address____________________________________City____________________________ State_______ Zip ___________
                            SECTION 3           Jr. Competitive–7th-12th grade ($50 late fee applies)^
                                      Check session(s) you are paying for
                     Fall – All – Aug. 24 start date             ____ $310(+$50 after 8/21/09)^ # @
                     Spring Varsity - Jan 4th start date         ____ $510(+ $50 after 1/11/10) ^ # @
                     Spring – all other – Feb 1st start date     ____ $435(+ $50 after 2/8/10) ^ # @
                     Spring – Coxswain –same dates as above ____ $360(+ $50 after 1/11/10 or 2/8/10) ^ # @
                     Summer –All- Start date- June 29th          ____ $180(+ $50 after 6/20/10) ^ # @
                                  # $25 yearly Membership fee for juniors is also due.
           2 children participating – 15% discount @@@@ 3 children participating – 20% discount


       Charles R Wood Summer Learn to Row – 7th-12th grade Check session (s) you are paying for.
                         1 Session                                  ____ $205             Session 1 ____ July 6 - July 17
                         2 Sessions (discounted)                    ____ $320             Session 2 ____ July 20- July 31
                         3 Sessions (discounted)                    ____ $420             Session 3 ____ Aug 3 – Aug 14
                         All sessions are for 2 weeks, 9AM-12PM Monday-Friday
                          Sculling Camps – ages 8-13                   Check session (s) you are paying for.
                              Summer Each session is 5 days, M-F 3 ¼ hours
                          Week 1 ____ $240 July 5-July 9                                9:00AM-12:00PM
                          Week 2 ___ $240 July 12-July 16                               9:00AM-12:00PM
                          Week 3 ____ $240 July 19-July 23                              9:00AM-12:00PM
                          Week 4 ____ $240 July 26-July 30                              9:00AM-12:00PM
                          Week 5 ____ $240 Aug 2-Aug 6                                  9:00AM-12:00PM
                          Week 6 ____ $240 Aug 16-Aug 20                                9:00AM-12:00PM
---------------------------------------------------------------------------------------------------------------------------------------
                    Fall Sculling Camps – Two Sessions:
                          Session A ____$185                   Tuesdays 4:00 PM – 5:30 PM (9/15 – 10/20)
                          Session B ____$185                   Thursdays 4:00 PM – 5:30 PM (9/17 – 10/22)
----------------------------------------------------------------------------------------------------------------------------- -------------------------
                     Queensbury Modified Sculling Program – grades 7 + 8
                         Fall – Sept 14 start date   _______$310 (+$50 after 9/21/09)
                         3 days per week – Mon, Wed, and Fri – 3:15 – 5:00PM. Program limited to 22 rowers.
        WE EXPECT EACH FAMILY TO VOLUNTEER AS PART OF OUR CLUB. IF YOU ARE UNABLE OR
                 UNWILLING THERE WILL BE A FEE ASSESSED TO YOUR ACCOUNT
                                                                    SECTION 4
                I am allowing my child(ren) listed below to row in the SRA session(s) checked above.
Child(ren) Name(s)_____________________________________________________Season(s)______________
There are no refunds and I agree to pay in full (even I am on a payment plan) if my child is unable to finish the
rowing season (except with a medical doctor’s note, in which case it will be prorated by month). Requests for
refunds must be in writing and emailed or mailed to SRA.
Parent signature ______________________________________________________Date_____________
I would like to make an additional donation to help another Jr. afford travel costs $___________

                    I am enclosing a check for or charging the total amount of: $____________

To charge payment: fill out below information with signature

Rower(s) Name____________________________________________ Season________________
Visa/MasterCard # _________________________________________ Exp Date_______/_______
Name on card:____________________________ Signature: ___________________________ Amount $______
All payments are due with registration and must be paid before your child begins rowing.
    Section 5
Release of Liability                                                I have read this agreement; fully understand its terms,
IN CONSIDERATION of being given the opportunity                     understand that I have given up substantial rights by
to participate in any activity with Saratoga Rowing                 signing it and have signed it freely and without any inducement
Association Inc (the ―Club’), Saratoga Rowing Properties            or assurance of any nature and intend it to be a complete and
LLC, as a rower, coach or volunteer, including scheduled,           unconditional release of all liability to the greatest extent
supervised Club activities, and registered regattas but not         allowed by law and agree that if any portion of this agreement is
limited to, all races and regattas, whether sponsored by the        held to be invalid, the balance, notwithstanding, shall continue in
Club or Club members, Club practices, workouts and other            full force and effect. This agreement is valid for the duration of
race preparations, and maintenance or construction of Club          your involvement with SRA.
facilities or equipment (each, an ―Activity‖), as of the
effective date of signature, I, for myself, my personal             Printed Name of Participant:
representatives, assigns, heirs, and next of kin.
1. I ACKNOWLEDGE, agree and represent that I understand             Date of Birth: ____________
the nature of Rowing Activities, both on water and land based,
and that I am qualified, in good health, and in proper physical     Address: _______________________________________
condition to participate in such Activity.
                                                                    City: _______________________ State:_____ Zip:______
2. I FULLY UNDERSTAND that: (a.) ROWING
ACTIVITIES INVOLVE RISKS AND DANGERS of serious                     Phone: ___________________Date:__________________
bodily injury, including permanent disability, paralysis and
                                                                    Participant’s Signature:
death (―Risks‖); (b.) these Risks and dangers may be caused
by my own actions, or inactions, the actions or inactions of
others participating in the Activity, the condition in which the
Activity takes place, or the negligence of the Releasees named      Organization: Saratoga Rowing Association Inc.
below; (c.) there may be other risks and social and economic
losses either not known to me or not readily foreseeable at this
                                                                    PARENTAL CONSENT( if participant is under the age of 18).
time; and I FULLY ACCEPT AND ASSUME ALL SUCH
RISKS AND ALL RESPONSIBILITY FOR LOSSES,
                                                                    AND I, the minor’s parent and/or legal guardian, understand the
COSTS, AND DAMAGES I incur as a result of my
                                                                    nature of rowing activities and the minor’s experience and
participation in the Activity.
                                                                    capabilities and believe the minor to be qualified to participate in
3. I AGREE AND WARRANT that I will examine and                      such activity. I hereby release, discharge, covenant not to sue,
inspect each Activity in which I take part as a member of the       and AGREE TO INDEMNIFY AND SAVE AND HOLD
Club or as a volunteer for the Club and that, if I observe any      HARMLESS each of the Releasees from all liability, claims,
condition which I consider to be unacceptably hazardous or          demands, losses, or damages on the minor’s account caused or
dangerous, I will notify the proper authority in charge of the      alleged to be caused in whole or part by the negligence
Activity and will refuse to take part in the Activity until the     of the Releasees or otherwise, including negligent rescue
condition has been corrected to my satisfaction.                    operations, and further agree that if, despite this release, I, the
                                                                    minor, or anyone on the minor’s behalf makes a claim against
4. I HEREBY RELEASE, discharge, and covenant not to sue             any of the above Releasees, I WILL INDEMNIFY, SAVE, AND
USRowing, the Club, the Regatta, their administrators,              HOLD HARMLESS each of the Releasees from any litigation
directors, agents, officers, volunteers and employees, other        expenses, attorney fees, loss, liability, damage, or cost any may
participating regatta organizers, any sponsors, advertisers, and    incur as the result of any such claim, to the fullest extent
if applicable, owners and lessors of premises, on which the         permitted by law.
Activity takes place, (each considered one of the Releasees         Printed Name of Parent/Guardian:
herein) from all liability, claims, demands, losses or damages
on my account caused or alleged to be caused in whole or in
part by the negligence of the Releasees or otherwise, including     Address: _____________________________________
negligent rescue operations that may arise or may have arisen
since the time of my first contacts with the Club and through       City ___________________State ______ Zip_______
all my future participation with the Club; and I further agree
that if, despite this release and waiver of liability, assumption   Phone: ________________
of risk, and indemnity agreement, I, or anyone on my behalf,
                                                                    Parent/Guardian Signature (only if participant is under the
makes a claim against any of the Releasees, I WILL                  age of 18):
INDEMNIFY, SAVE AND HOLD HARMLESS each of the                       XX_____________________________________
Releasees from any litigation expenses, attorney fees, loss,
liability, damage, or cost which any may incur as a result of       Date:_________________
such claim, to the fullest extent permitted by law.                                                             Page 3
                                                          SECTION 6

                                  SRA ALCOHOL SUBSTANCE USE POLICY
Being part of a team and the Saratoga Rowing
Association is a great opportunity to broaden oneself and        CONSEQUENCES
develop strength of character. You owe it to yourself to         Any violation of the SRA alcohol substance abuse
get the best of your education and your athletic
                                                                 policy by an SRA member could result in, but not
experiences.
                                                                 limited to:
CONDUCT OF AN ATHLETE                                            1. Benching
The conduct of an athlete is closely observed in many            2. Probation
areas of life; during competition, in the classroom, and in      3. Suspension
the community. An SRA athlete should always project a            4. Appropriate intervention
positive image. The following rules are in effect for all        5. Removal from the team.
SRA athletes.                                                    Alleged offenses may be reported in writing to the Board of
1. No hosting of parties where consumption of                    Directors which will then submit it to the Disciplinary
alcohol                                                          Committee or brought to a coach or committee directly.
or drugs/controlled substances are used                           The Committee will be nonbiased consisting of
2. No consumption of tobacco                                     volunteers from law enforcement, substance abuse
3. No consumption of alcoholic beverages                         prevention organizations, and the community at large. This
4. No consumption of illegal drugs or mood                       committee will investigate any alleged activity as well as
                                                                 speak to the athlete and their parent(s) in order to determine
altering substances
                                                                 the necessary consequences. The determination and
5. Rules are in effect all year.                                 recommendation of this committee are final.
Hosting of Drinking/Drug Parties- Student athletes               Out of Season Violations to the Athletic Standards:
hosting a party that involves any alcohol, drugs, or other       As previously stated, no use all year, in or out of season.
controlled substances will be subject to review by the           Athletes are athletes all year. They are responsible for their
Association’s Disciplinary Committee and could result in         actions at all times. Any SRA athlete in violation of this
disciplinary action being taken. An athlete of the SRA           code must illustrate some degree of rehabilitation in the off
represents our organization at all times. An athlete’s           season.
involvement in inappropriate behavior both previously            An athlete must show some written evidence of addressing
defined or implied, even when not ―in season‖ would              the problem. Written proof must be sent to the Disciplinary
necessitate disciplinary review.                                 Committee that the student/athlete has addressed their
Use/Possession of Tobacco-Tobacco is physically                  problem.
harmful to young adults. The harm done by this is not            If approval is granted by the Committee the athlete will then
only a health problem. The community follows the                 rejoin the team at a time specified by the Committee.
progress of SRA athletes, and any deviation from                 Whistle Blower Reprisal
accepted training rules marks one as unwilling ―to pay the       The disciplinary committee will take action against any
price‖. If one squad member breaks the rules, the whole          team member, volunteer, or coach who retaliates against a
team is branded as non-trainers.                                 person who makes a good faith report of alleged misconduct
This rule means no use of tobacco all year, in or out of         of another athlete.
season.                                                          Participation in the Saratoga Rowing Association is a
No Consumption/Possession of Alcoholic Beverages-                privilege which should elicit great pride in both the athlete
Even though social pressures may be hard to resist, there        and the parent. Standards of behavior and training are high
is no way to justify athletes using alcoholic beverages. It      and a willingness to live up to them is a part of being a
is unhealthy and illegal. This rule means no drinking all        member of the team. For this reason each athlete must sign
year, not just during the season.                                this agreement as a personal commitment to this team as
                                                                 well as their teammates and a willingness to set a positive
Drugs- Drug abuse is the consumption of any chemical             example and follow proper training practices.
substance or the smoking of some plant derivatives for the       Rower Signature________________________________
purpose of mood modification. Students with a strong
sense of self and purpose have no need for mood                  Printed Rower Name ____________________________
modifiers.
The substance use policy is in effect for the duration of        Parent Signature ________________________________
your involvement with SRA.
                                                                 Date ____________                             Page 4
           Fill out either section 7 OR 8

                    SECTION 7*                               SECTION 8* -do not fill out if sec. 7 is signed

 SARATOGA ROWING ASSOCIATION, INC.                         SARATOGA ROWING ASSOCIATION, INC.
    CONSENT TO TAKE AND PUBLISH                            DECLINATION OF CONSENT TO TAKING
           PHOTOGRAPHS                                              OR PUBLICATION
   OR VIDEO RECORDINGS OF CHILD                                OF PHOTOGRAPHS OR VIDEO
                                                                 RECORDINGS OF CHILD
CHILD’S NAME: _________________________________
                                                          CHILD’S NAME: _________________________________
        I, _______________________________, am            I, ______________________________________, am
the ______________________________ of                     the _________________________________ of
_______________________________________,                  ________________________________, and I do
and I do hereby consent to the taking of photographs      hereby decline to give my consent to the taking,
or video recordings of my child or ward by any            publication or posting of any photographs or video
coach, assistant coach, manager, officer, director or     recordings of my child or ward by any coach,
other authorized agent of Saratoga Rowing                 assistant coach, manager, officer, director or other
Association, Inc. during any Saratoga Rowing              authorized agent of Saratoga Rowing Association,
Association, Inc. game, tournament, practice, tryout      Inc.
or other club activity participated in by my child or
ward as a member or candidate for membership in                   I further acknowledge and agree that
Saratoga Rowing Association, Inc..                        Saratoga Rowing Association, Inc. shall not be
                                                          responsible for the taking or use of any photographs
         I further acknowledge and give my consent to
                                                          or video recordings of my child or ward by any other
Saratoga Rowing Association, Inc. publicizing
                                                          parent, family member, spectator or member of the
photographs or video recordings taken of my child or
                                                          press attending activities participated in by Saratoga
ward by any person in any promotional literature
                                                          Rowing Association, Inc. and I agree to hold
publicizing Saratoga Rowing Association, Inc.’s
                                                          Saratoga Rowing Association, Inc. harmless for the
activities, such activities including, but not being
                                                          taking or use of any such photographs or video
limited to, club tryouts, practices, races and regattas
                                                          recordings.
and I further consent to Saratoga Rowing
                                                          __________________________________
Association, Inc. posting and displaying photographs
                                                          Parent/Guardian/Custodian Signature
or video recordings taken of my child or ward by any
                                                          ___________________
person on Saratoga Rowing Association, Inc.’s
                                                          Date
website.
                                                          ____________________________________
       I further acknowledge and agree that               Parent/Guardian/Custodian Printed Name
Saratoga Rowing Association, Inc. shall not be
responsible for the taking or use of any photographs
or video recordings of my child or ward by any other
parent, family member, spectator or member of the
press attending any activities participated in by
                                                          Amasters\Not for Profits\SRA\3991 SRA Photo Yes.doc File No. 3991
Saratoga Rowing Association, Inc. and I agree to          12/15/2008
hold Saratoga Rowing Association, Inc. harmless for
the taking or use of any such photographs or video        Amasters\Not for Profits\SRA\3991 PhotoNo.doc File No 3991Rev.12/2/2008
recordings.
                                                          *This document is valid for all membership years or
____________________________________                      until child reaches the age of 18 years.
Parent/Guardian/Custodian Signature
__________________________
Date
____________________________________                                                                        Page 5
Parent/Guardian/Custodian Printed Name
     SECTION 9*

TRAVEL—RULES, REGULATIONS AND
EXPECTATIONS

GENERAL RULES                                              HOTEL RULES CONTINUED
1. At all times, athletes will show respect and courtesy   20. Keep your rooms clean—they will be inspected. If
towards, and cooperation with, and must follow the         a room fails inspection, each occupant may forfeit the
decisions of the chaperones and coaches.                   next special activity.
2. Under no circumstances may athletes go anywhere         21. Chaperones and coaches have the right to enter and
alone.                                                     inspect a room at any time.
3. An athlete may not leave an assigned group or           22. There will be no mixed groups in hotel rooms.
chaperone under any circumstances.                         Mixed groups are allowed only in the common rooms
4. Assigned chaperones must know where the athletes        or in chaperoned rooms.
are at all times. It is the athlete’s responsibility to    23. NO STRANGERS are allowed in any rooms.
notify the chaperones.                                     24. Do not prop open the hotel doors or open the
5. The SRA Medicine Permission Slip must be given to       outside doors for strangers. This protects all of us!
SRA prior to departure indicating all prescription and     25. Athletes are expected to participate in all practices
non-prescription medications that will be brought on       and planned activities.
the trip.
6. Any athlete who needs to call a doctor during the       CONSEQUENCES
trip will be responsible for the bill.                     26. Each athlete will be responsible for any damage to
7. There will be no drinking of alcoholic beverages,       or loss of property on the trip.
drug use or smoking at any time on the trip.               27. Any athlete who fails to comply with any of the
8. Each athlete is responsible for everything he or she    above, may:
brings.                                                         1. Have restrictions placed on him/her
9. Everyone is expected to eat properly and drink               2. May be returned home at the parents’ expense
plenty of fluids, and wear sunscreen.                           3. May be prohibited from traveling with the
10. All athletes will have a trip buddy throughout the              team
trip. You are responsible for each other at all times.          4. May be dismissed from the team
11. NEVER SWIM ALONE, and always swim with
buddy AND coaches/chaperones supervision/rules.
                                                           Rower Signature: _____________________________
 BUS RULES
12. THE BUSES WILL LEAVE ON TIME.                          Date: __________
ARRIVE PROMPTLY to the meeting place.
13. Each Athlete is limited to one suitcase and one        Rower Printed Name: __________________________
carry-on, and may need to help with team items.
14. No one may change bus without permission from
the coach or chaperone.                                    Parent Signature: ______________________________
15. Athletes are responsible for notifying parents
WHEN WE REACH ALBANY (wake up your                         Date: __________
buddy if necessary) so that parents will be at Wal-Mart
when the bus arrives.                                      Parent Printed Name: __________________________

HOTEL RULES
16. No one will change hotel room assignment without
permission from the coach or chaperone.                    *This document is valid for all membership years or
17. Athletes must stay in their rooms after curfew.        until child reaches the age of 18 years.
18. Do not leave money or valuables in unattended
rooms.
                                                           Corporations/not for profits/SRA Travel doc. Rev. 12/2/08
19. Be considerate of others: no excessive noise,
roaming the halls, horseplay, etc. in the hotel or
elevators.                                                                                                       Page 6

								
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