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Informed Consent and Assumption of Risk Agreement
(To be executed by Individuals under the age of Majority)
WARNING! By signing this document you will assume certain risks and responsibilities. Please read carefully
Individual’s Name: _____________________________ Parent/Guardian Name: ________________________
(for individual’s 17 and under)
1. This is a binding legal agreement; therefore clarify any questions or concerns before signing. As an Individual
member in the sport of volleyball and/or the events, programs, competitions, travel, and activities organized,
operated or conducted and/or sanctioned by Volleyball Alberta (collectively the “Activities”), the undersigned
acknowledges and agrees to the following terms.
Disclaimer
2. Volleyball Alberta, member clubs, and all the respective, directors, officers, committee members, members,
employees, coaches, volunteers, referees, participants, agents, sponsors, and representatives, and owners/operators
of the event facilities (collectively the Organization) are not responsible for any injury, property damage, death,
expense, loss of income, damage or loss of any kind suffered by the Individual during, or as a result of, the Activities.
We have read and agree to be bound by paragraphs 1 and 2
Description of Risks
3. The Parties understand and acknowledge that:
a) The Activities have foreseeable and unforeseeable inherent risks, hazards and dangers that no amount of care,
caution or expertise can eliminate, including without limitation, the potential for serious bodily injury, permanent
disability, paralysis and loss of life; and
b) The Organization has a difficult task to ensure safety but it is not infallible. The Organization may be unaware of
the Individual’s fitness or abilities, may give incomplete warnings or instructions, and the equipment being used
might malfunction.
4. In consideration of the Individual’s involvement in the Activities, the Parties hereby acknowledge that they are
aware of the risks, dangers and hazards and may be exposed to such risks, dangers and hazards. The risks, dangers
and hazards include, but are not limited to:
a) The sport of volleyball;
b) Executing strenuous and demanding physical techniques;
c) The failure to properly use any piece of equipment or from the mechanical failure of any piece of equipment;
d) Physical contact with other Individuals, participants, spectators, equipment and hazards;
e) Contact with, colliding with, or being struck by the volleyball, net, poles, benches, equipment, or other
Individuals, participants, or spectators
f) Spinal cord injuries which may render the Individual permanently paralyzed;
g) Serious injury to virtually all bones, joints, ligaments, muscles, tendons and other aspects of the Individual’s body
or to the Individual’s general health and well-being;
h) Abrasions, sprains, strains, fractures, or dislocations;
i) Concussion or other head injuries, including but not limited to, closed head injury or blunt head trauma;
j) Failure to act safely or within the Individual’s own ability or within designated areas;
k) Negligence of other persons, including other Individuals, spectators, participants, or employees; and
l) Travel to and from the event which is an integral part of the Organization’s Activities.
We have read and agree to be bound by paragraphs 3 and 4
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Terms
5. In consideration of the Individuals involvement in the Activities, the Parties agree:
a) That the Individual’s mental and physical condition is appropriate, and the Parties assume all risks related to the
Individuals mental or physical condition;
b) To comply with the rules of the facility and equipment;
c) That if the Individual observes an unusual significant hazard or risk, the Individual will remove himself/herself
from the area and bring such to the attention of an Organization representative immediately;
d) That the Organization may not provide full health, accident, disability, hospitalization, personal property or other
insurance for the Individual and the Parties affirm that they have ascertained appropriate insurance to protect
the Individual; and
e) The risks associated with the Activities are increased when the Individual is impaired and the Individual agrees
not to become involved if impaired in any way.
Release of Liability
b. In consideration of the Individuals involvement in the Activities, the Parties agree:
a) That the Parties are not relying on any oral or written statements made by the Organization or their agents,
whether in brochure or advertisement or in individual conversations, to agree to be involved in the Activities; and
b) To freely accept and fully assume all such risks, dangers and hazards, and possibility of personal injury, death,
property damage, expense and related loss, including loss of income, resulting from the Individual’s involvement
in the Activities and travel to and from the Activities.
We have read and agree to be bound by paragraphs 5 and 6
General
c. The Parties agree that in the event that they file a lawsuit against the Organization, they agree to do so solely in
the province of Alberta, Canada and they further agree that the substantive law of Alberta will apply without
regard to conflict of law rules.
d. The Parties expressly agree that this Agreement is intended to be as broad and inclusive as is permitted by law
and that if any of its provisions are held to be invalid, the balance shall, notwithstanding, continue in full legal
force and effect.
Acknowledgement
e. The Parties acknowledge that they have read this agreement and understand it, that they have executed this
agreement voluntarily, and that this Agreement is to be binding upon themselves, their heirs, their spouses,
parents, guardians, next of kin, executors, administrators and legal or personal representatives. The Parties
further acknowledge by signing this agreement they have waived the right to maintain a lawsuit against the
Organization on the basis of any claims from which they have released herein.
____________________________ _____________________________ _____________
Name of Individual (print) Signature of Individual Date of Birth
____________________________ _____________________________ _______________
Name of Parent or Guardian (print) Signature of Parent or Guardian Date
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Volleyball Alberta Policy Acknowledgement Form: Referees
As an individual affiliated with Volleyball Alberta for the current season (September 1 August 31), I agree to adhere to
and abide by Volleyball Alberta’s policies and procedures, which include:
Code of Conduct and Ethics
Discipline and Complaints Policy
Scouting and Recruiting Policy
Privacy Policy
Refund and Cancellation Policy
Screening Policy
Concussion Policy and Protocol
Use of Personal Information
Social Media Guidelines
Appeal Policy
Transgender Inclusion Policy
VAO Policies & Procedures
I have the following role with Volleyball Alberta for the ____________________ season:
Referee in Zone:
I also recognize that I must adhere to additional standards particular to my role(s), which are described in the Code of
Conduct and Ethics.
______________________ ______________________ _________________
Name of Individual Signature Date
_____________________ ______________________ _________________
Parent/Guardian Name (If Individual is 17 or under) Parent/Guardian Signature Date
__________________________________________________________________________________________________
Parent’s/Guardians of Referee’s who are younger than 18:
Parents/Guardians must agree on behalf of their minor as well as accept the policies on their own behalf in their role as
a parent/guardian.
As a parent/guardian affiliated with Volleyball Alberta for the _____________ season (September 1 August 31), I agree
to adhere to and abide by Volleyball Alberta’s policies and procedures listed above. I also recognize that I must adhere
to additional standards particular to my role(s), which are described in the Code of Conduct and Ethics.
_____________________ ________________________________ _________________
Parent/Guardian #1 Name Parent/Guardian #1 Signature Date
________________________________ _________________
____________________
Parent/Guardian #2 Name
Parent/Guardian #2 Signature Date
__
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Pre-Season Concussion Education Sheet
WHAT IS A CONCUSSION? A concussion is a brain injury that can’t be seen on x-rays, CT or MRI scans. It affects the way
an athlete thinks and can cause a variety of symptoms.
WHAT CAUSES A CONCUSSION? Any blow to the head, face or neck, or somewhere else on the body that causes a
sudden jarring of the head may cause a concussion. Examples include getting body-checked in hockey or hitting one’s
head on the floor in gym class.
WHEN SHOULD I SUSPECT A CONCUSSION? A concussion should be suspected in any athlete who sustains a significant
impact to the head, face, neck, or body and reports ANY symptoms or demonstrates ANY visual signs of a concussion. A
concussion should also be suspected if an athlete reports ANY concussion symptoms to one of their peers, parents,
teachers, or coaches or if anyone witnesses an athlete exhibiting ANY of the visual signs of concussion. Some athletes
will develop symptoms immediately while others will develop delayed symptoms (beginning 24-48 hours after the
injury).
WHAT ARE THE SYMPTOMS OF A CONCUSSION? A person does not need to be knocked out (lose consciousness) to
have had a concussion. Common symptoms include:
Headaches or head pressure
Feeling slowed down
Difficulty reading
Dizziness
Easily upset or angered
Difficulty learning new information
Nausea and vomiting
Sadness
Not thinking clearly
Blurred or fuzzy vision
Nervousness or anxiety
Difficulty working on a computer
Sensitivity to light or sound
Feeling more emotional
Having a hard time falling asleep
Balance problems
Sleeping more or sleeping less
Feeling tired or having no energy
WHAT ARE THE VISUAL SIGNS OF A CONCUSSION? Visual signs of a concussion may include:
Blank or vacant stare
Clutching head
Facial injury after head trauma
WHAT SHOULD I DO IF I SUSPECT A CONCUSSION? If any athlete is suspected of sustaining a concussion during sports
they should be immediately removed from play. Any athlete who is suspected of having sustained a concussion during
sports must not be allowed to return to the same game or practice. It is important that ALL athletes with a suspected
concussion undergo medical assessment by a medical doctor or nurse practitioner, as soon as possible. It is also
important that ALL athletes with a suspected concussion receive written medical clearance from a medical doctor or
nurse practitioner before returning to sport activities.
WHEN CAN THE ATHLETE RETURN TO SCHOOL AND SPORTS? It is important that all athletes diagnosed with a
concussion follow a stepwise return to school and sports-related activities that includes the following Return-to-School
and Return-to-Sport Strategies. It is important that youth and adult student-athletes return to full-time school activities
before progressing to stage 5 and 6 of the Return-to-Sport Strategy.
Canadian Guideline on Concussion in Sport | Pre-Season Concussion Education Sheet www.parachutecanada.org/concussion
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Return-to-School Strategy
1
Stage
Aim
Activity
Goal of each step
1
Daily activities at home
that do not give the
student-athlete
symptoms
Typical activities during the day as long as they do not
increase symptoms (i.e. reading, texting, screen time).
Start at 5-15 minutes at a time and gradually build up.
Gradual return to typical
activities
2
School activities
Homework, reading or other cognitive activities
outside of the classroom.
Increase tolerance to cognitive
work
3
Return to school part-
time
Gradual introduction of schoolwork. May need to start
with a partial school day or with increased breaks
during the day.
Increase academic activities
4
Return to school full-
time
Gradually progress
Return to full academic activities
and catch up on missed school
work
Volleyball-Specific Return-to-Sport Strategy
1
Stage
Aim
Activity
Goal of each step
1
Symptom-limiting
activity
Daily activities that do not provoke symptoms
Gradual re-introduction of
work/school activities
2
Light aerobic
activity
Walking or stationary cycling at slow to medium pace. No
resistance training
Increase heart rate
3
Sport-specific
exercise
Running drills. No head impact activities
Add movement
4
Non-contact
training drills
Harder training drills, i.e. attacking drills. May start
progressive resistance training
Exercise, coordination and
increased thinking
5
Full contact
practice
Following medical clearance and complete return to school.
Restore confidence and assess
functional skills by coaching staff
6
Return to sport
Normal game play
1 Source: McCrory et al. (2017). Consensus statement on concussion in sport the 5th international conference on concussion in sport
held in Berlin, October 2016. British Journal of Sports Medicine, 51(11), 838-847. http://dx.doi.org/10.1136/bjsports-2017
HOW LONG WILL IT TAKE FOR THE ATHLETE TO RECOVER? Most athletes who sustain a concussion will make a
complete recovery within 1-2 weeks while most youth athletes will recover within 1-4 weeks. Approximately 15-30% of
patients will experience persistent symptoms (>2 weeks for adults; >4 weeks for youth) that may require additional
medical assessment and management.
HOW CAN I HELP PREVENT CONCUSSIONS AND THEIR CONSEQUENCES? Concussion prevention, recognition and
management require athletes to follow the rules and regulations of their sport, respect their opponents, avoid head
contact, and report suspected concussions. To learn more about concussions, please visit:
www.parachutecanada.org/concussion
The following signatures certify that the athlete and his/her parent or legal guardian have reviewed the above
information related to concussion.
___________________________________ ____________________________ ______________
Printed name of Individual Signature of Individual Date
___________________________________ ____________________________ ______________
Printed name of parent (If Individual is 17 or under) Signature of parent Date
Canadian Guideline on Concussion in Sport | Pre-Season Concussion Education Sheet www.parachutecanada.org/concussion
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