Pole Vault Summit

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Pole Vault Summit & Coaches Certification 9:00am - 3:00pm Iolani Schools Track Saturday, February 11, 2012. Coaches Free Athletes $20.00 For more info contact Joel Floes at (808)381-5530 or email: joel@lava.net

Hawaii Pole Vault Education Clinic

Informed Consent and Assumption of Risks

There are certain inherent risks in almost every activity. It is the athlete’s responsibility to assess athlete’s maturity and fitness and determine if the risks associated with this activity are acceptable. While we sincerely hope that every participant enjoys an injury-free activity, by your signing this form, you assume all risks associated with the activity for which you have registered. Please ask any questions of the instructor that you may need to make a fully informed decision to participate. In consideration of my participating, I hereby release and covenant not-to-sue HHSAA, USATF, the State of Hawaii, Iolani School, and any of their employees, teachers, coaches, or agents, from any and all present and future claims resulting from ordinary neg­ligence on the part of instructors or others listed for property damage, personal injury, or wrongful death, arising as, a result of my engaging in or receiv­ing instruction in running, jumping, gymnastics, throwing, or any other activities or any activities incidental thereto, wherever, whenever, or however the same may occur. I hereby voluntarily waive any and all claims resulting from ordinary negligence, both present and future, that may be made by me, my family, estate, heirs, or assigns.

Further, I am aware that activities like pole vaulting are vigorous sporting endeavors involving height and rotation in a unique environment and as such they pose a risk of injury. I understand that pole vault and related activities always involve certain risks, including but not limited to, death, serious neck and spinal injuries resulting in complete or partial paralysis, brain damage, and serious injury to virtually all bones, joints, muscles, and internal organs, and that the mats, pits, and other safety equipment and apparatus provided for my protection, including the active participation of a coach or teacher who will spot or assist in the performance of certain skills, may be inadequate to prevent serious injury. The risk of harm may be limited by all of the safety equipment and trained coaches, but never eliminated. I understand that participation in gymnastics and related activities involves many actions incidental to active participation, including moving from event to event, conditioning, stretching and other activities that may leave me vulnerable to the reckless actions of other participants who may not have complete control over their actions or who may not see me or other students in the gym. I am voluntarily participating in this activity with knowledge of the risks involved and hereby agree to accept any and all inherent risks of property damage, personal injury, or death.

As additional consideration for permission to participate in Academy activities, I agree to indemnify, save and hold harmless clinic instructors, agents, employees, and officers from any and all deaths, injuries, losses and damages to persons or property, and any and all claims, demands, suits, actions and liability there­fore, caused by the participant’s participation in any Academy activities. I further agree to indemnify and hold harmless PVH and all others listed for any and all claims arising as a result of my engaging in or receiving instruction in PVH activities or any activities incidental thereto, whenever, wherever, or however the same may occur.

I understand that this waiver is intended to be as broad and as inclusive as permitted by the laws of the state of Hawai’i and agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceedings shall be within the state of Hawai’i.

Consent for Emergency Treatment

In the event of an emergency (disaster, injury or illness), I authorize Pole Vault Hawaii coaches and/or agents to seek medical attention for me/my child(ren), as they deem necessary, and authorize treatment, if I (or others listed on this form) cannot be reach. Personal medical insurance is required of all students par­ticipating in PVH activities and I verify that coverage is adequate and current.

Athlete Information

Name: _____________________________________________________________________  USATF#: _______________

Date of Birth: _________________________________________________  Age: ________________  Sex: _____________

School/Work/Occupation: ______________________________________________  Grade/Level: _____________________

Athlete Phone/Cell: ______________________________________ Alt Phone: ____________________________________

Athlete Email: _____________________________________________   Website: _________________________________

Previous Experience (please circle one):       No Experience           Beginner           Intermediate           Advanced

Special Instructions/Comments:

Medical Information

Please List Any Medical Conditions or Other Pertinent Information Such as Physical/Mental Handicaps

Emergency Contact Information

Contact Name: ______________________________________  Phone: ______________  Relationship: ________________

Physician: _________________________________  Phone: ___________________  Insurance Provider: ______________

Acknowledgement of Consent

I have read the Informed Consent, Assumption of Risk, Release of Claims, and Indemnification Form (on the back of this page) for the activities indicated, know the content thereof, and agree to all conditions.

Participant Name (please print): ___________________________________________________ Date: _________________

If participant is under 18 years of age

Parent/Guardian Signature: ________________________________________________________________________________

Parent/Guardian Name (please print): ______________________________________________ Date: _________________