OLYMPIA LIABILITY / COVID WAIVER

Welcome to the online Liability / COVID waiver form for OLYMPIA.

ALL players playing in a league or tournament that is run by a Karidis Group International company (Juventus Academy Saint Louis, Olympia, or PAO Volleyball) or renting training space at Olympia will need to complete this Liability / COVID waiver.

- Leagues / Tournaments will need to complete a new form for each tournament and/or League played

If you have any questions, please contact us at...

Juventus Academy STL Leagues & Tournaments

E-Mail: tournaments@juventusacademystl.com
Phone: (636) 429-1908

James "JT" Thomas | Olympia General Manager

E-Mail: info@olympiaathletic.com
Phone: (636) 329-4949

Thank You For Your Support

PARTICIPANT INFORMATION

PLAYER FIRST NAME *

PLAYER LAST NAME *

B'DAY (MM/DD/YYYY) * +

PARTICIPANT GENDER *

MALE

FEMALE

NAME OF EVENT *

Futsal Festival 2022

Winter Indoor League

OTHER (please explain in box below) OTHER (please explain in box below)

CLUB / TEAM NAME *

COACH NAME *

TEAM AGE GROUP *

PARTICIPANT SPORT *

Soccer

Futsal

3v3

PARTICIPANT ADDRESS (street, city, state, zip) *

PARTICIPANT MEDICAL INFORMATION

PARTICIPANT DOCTOR (First & Last) *

DR PHONE NUMBER *

INSURANCE COMPANY *

INSURANCE PHONE NUMBER *

POLICY HOLDER NAME (First & Last) *

POLICY NUMBER *

GROUP NUMBER *

ALLERGIES / MEDICAL CONDITIONS (If "none" type N/A in box.)

PARENT/LEGAL GUARDIAN INFORMATION

PARENT NAME (First & Last) *

Relationship *

PARENT CELL *

PARENT E-MAIL ADDRESS *

2nd CONTACT NAME (First & Last) *

Relationship *

2nd Contact CELL *

2nd Contact E-MAIL ADDRESS *

EMERGENCY CONTACT INFORMATION

CONTACT NAME (First & Last) *

Relationship to Player *

CONTACT CELL *

COVID AGREEMENT

HEALTH CONFIRMATION *

I will NOT bring my child, or anyone in our family, to a training/game if they have displayed any symptoms associated with COVID19, including but not limited to, a temperature of 100.4 or higher, a persistent cough, (not allergy related), shortness of breath or trouble breathing, sore throat (different from allergies), have a loss of taste/smell, diarrhea or vomiting, abdominal pain, or any indications of not being well and healthy.

I will NOT bring my child to a training/game if they have been quarantined by their school and/or the Department of Public Health.

I will NOT bring my child to a training/game if they have had direct exposure to someone who has tested positive for COVID19 from the 48 hours prior to when they showed symptoms through the end of their quarantine period. Direct physical contact is defined by the St Charles County Department of Public Health as being within 6 feet of the person, while not wearing a mask, for 15 minutes or longer.

PLAYER COVID19 RESTRICTIONS *

I understand and will explain to my child that IF they are a goalkeeper, spitting on their gloves is PROHIBITED.

I understand and will explain to my child that spitting on their bottom of their shoes is PROHIBITED.

I understand and will explain to my child that spitting on the court/field is PROHIBITED.

I understand and will explain to my child that sharing water bottles/drinks is PROHIBITED.

POSSIBLE COVID19 EXPOSURE AGREEMENT *

I understand that if my child or any spectator from my family tests positive for COVID during or within 48 hours of the end of the tournament, I will notify Juventus Academy STL at tournaments@juventusacsdemystl.com and/or 636-429-1908 so we can work with the Health Department to determine contact tracings needed.

I understand that if my child or any spectator from my family tests finds out they were exposed to someone who is believed to have COVID or who tests positive for COVID during or within 48 hours of the end of the tournament, I will notify Juventus Academy STL at tournaments@juventusacsdemystl.com and/or 636-429-1908 so we can work with the Health Department to determine contact tracings needed.

I understand that if my child or any spectator from my family shows any of the symptoms outlined in the Health Confirmation section above during or within 48 hours of the end of the tournament, I will notify Juventus Academy at tournaments@juventusacsdemystl.com and/or 636-429-1908 so we can work with the Health Department to determine contact tracings needed.

LIABILITY / WAIVER RELEASE AGREEMENT

By signing below, I agree to the medical and waiver release agreement. I the undersigned (if applicant/participant is 18 years of age or older) or parent/guardian of the above listed minor applicant/participant acknowledge that I have been advised of the risks involved in my son’s/daughter’s participation at Olympia Athletic Centre and have been made aware that his/her participation may result in injury or harm to my son/daughter and I assume responsibility for any and all such risk to my son/daughter. In the event that my son/daughter may sustain an injury as a result of their participation, I hereby agree to hold harmless; Karidis Group International, Olympia Athletic Centre, Juventus Football Club, Juventus Academy Saint Louis, it’s directors, officers, coaches, athletic trainers, supervisors, and any other employees or agents there of including those who transport them to/from tryouts, practices, and games, for any and all such injuries. I hereby give my consent to have an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I hereby authorize emergency transportation of my son/daughter to a medical treatment facility should an individual listed previously deem warranted. I affirmatively certify that to the best of my knowledge, my son/daughter is in good mental and physical health and capable of participating in this activity. I have read and fully understand the contents of this “hold harmless” agreement and execute same voluntary. If requested by Karidis Group International, Olympia Athletic Centre, Juventus Football Club, or Juventus Academy Saint Louis staff, I agree to modify his/her activities as directed. I further give my permission for the free use of the participants name and image/video in broadcast, telecast, or any other media account of any and all event/activities and for the promotional purposes of the Karidis Group International, Olympia Athletic Centre, Juventus Football Club, or Juventus Academy Saint Louis. I also understand that my personal information will not be sold to any outside party and will only be used for contact and or marketing for the following; Karidis Group International, Olympia Athletic Centre, Juventus Football Club, and Juventus Academy Saint Louis.

COVID19 ADDITION:

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by participation and attending games as a spectator; and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Olympia may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Juventus FC, Juventus Academy Saint Louis, and Olympia, as well as their employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself and my child (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my participation at training/games at Olympia. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless Juventus FC, Juventus Academy Saint Louis, Karidis Group International, and Olympia, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Juventus FC, Juventus Academy Saint Louis, Karidis Group International, and Olympia, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation at Olympia.

I, THE UNDERSIGNED BELOW; UNDERSTAND & AGREE TO THE ABOVE LIABILITY/COVID19 RELEASE FORM. *

I AGREE TO THE ABOVE LIABILITY / RELEASE FORM

RELATIONSHIP TO PARTICIPANT *

TODAY'S DATE * +

PARENT / LEGAL GUARDIAN SIGNATURE *

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