U.S. BASEBALL & SOFTBALL ACADEMY – HEALTH & RELEASE FORMS

(You will not be admitted to camp without this form, completed and signed on all pages.)
Please enter the name of the site as listed on your registration confirmation.

ADDITIONAL AUTHORIZED CONTACTS IN CASE OF EMERGENCY AND FOR PICK-UPS

 

HEALTH & GENERAL HISTORY

In the following section, please answer each question. If the answer is none or does not apply to your camper, answering "none" is acceptable or "N/A"

Examples include: Asthma, Chicken Pox, COVID-19, Diabetes, Epilepsy, German Measles, High Blood Pressure, Measles, Mumps, Poliomyelitis, Rubella, Whooping Cough

IMMUNIZATIONS

Please input dates for the immunizations listed below. If you are unsure of the exact date, but know the Camper has received the immunization, please input “Y” in the “DATE” field. If the Camper has not received the immunization, or you are unsure, please leave the field empty.

DATE
DATE
DATE
DATE
DATE

Because our camp programs have a potential for communicable diseases, we recommend that program participants are appropriately immunized for, at minimum, the following diseases: tetanus, mumps, measles, rubella, polio, pertussis (whooping cough), and diphtheria. This being said, we recognize that some individuals may not be fully immunized for reasons that are biophysical (e.g., the individual is allergic to a serum component) or of personal choice (e.g., faith belief). 

If Camper has NOT been fully immunized for biophysical or personal choice reasons. Please sign the following statement: I understand and accept the risks to my child from not being fully immunized.

Clear Signature

HEALTH INSURANCE INFORMATION

 

AUTHORIZATION FOR MEDICAL CARE

I, the parent (guardian) of the camper named on this form, give permission for the named camper to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that good faith attempt will be made to contact me, or the emergency contact named above, before taking this action. I will be financially responsible for any medical attention needed during camp or  resulting from an injury received at camp. My medical insurance shall be the sole insurance coverage for any medical treatment. I further agree that my child can receive over the counter remedies. (Tylenol, Sudafed, etc.)

On behalf of myself and the Camper, I acknowledge and agree as follows:

  1. I am the parent or legal guardian of the Camper.  The Camper is capable of safely participating in the Camp and related activities, and all activity restrictions, allergies, and medications applicable to the Camper are listed in the forms above.
  2. In the event of an emergency or non-emergency situation requiring medical or dental treatment, I hereby grant permission to Camp staff for any and all medical or dental care to be administered to the Camper, including, but not limited to, the administration of first aid, the administration of an epinephrine auto-injector, and the use of an ambulance.  I also hereby authorize Camp staff, acting as my agent, to consent to the following for the Camper: (i) any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician or surgeon licensed in the state, county, or other locality where the physician or surgeon is located, or (ii) any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care by a dentist licensed in the state, county, or other locality where the dentist is located, or (iii) the foregoing in clauses (i) and (ii) administered or performed by the staff of any acute general hospital holding a current license to operate a hospital in the state, county, or locality where it is located.  I understand that a good faith attempt will be made to contact me, or the emergency contact named above, before consenting to any of the foregoing in clauses (i), (ii) or (iii) above.
  3. I understand that this authorization is being given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power to Camp staff to give specific consent to any and all such diagnosis, treatment, or hospital care which an aforementioned physician, dentist, or staff in the exercise of his or her best judgment may deem advisable.
  4. I understand that it is important that USBSA and the Camp have my permission to share the medical care and emergency contact information of the Camper with the involved Camp staff. My signature below authorizes these individuals to access the Camper’s medical and emergency records on file with USBSA and/or the Camp and to share this information with involved Camp staff or emergency medical personnel, hospital, or other health care professional who evaluates, diagnoses, or treats an injury, illness, or other condition incurred by the Camper, as deemed necessary by Camp staff.
  5. I understand and acknowledge that I am responsible for, and agree to fully pay, all costs of medical and/or dental care incurred by the Camper and rendered pursuant to the authorizations given in this Authorization for Medical Care, including, but not limited to, the cost of medical evacuation, paramedic transportation, hospitalization, and any examination, x-ray, or other treatment provided pursuant to the authorizations given in this Authorization for Medical Care. I further understand and agree that my insurance is primary and non-contributory to any insurance that USBSA and/or the Camp may carry. I hereby, on behalf of myself and the Camper, release, forever discharge, and will hold harmless USBSA, the entity operating the Camp, and the owner of the facility at which the Camp is operated (and their respective directors, officers, employees, officials, affiliates, sponsors, hosts, agents, assigns, subsidiaries, owners, partners, and joint venturers) (collectively, the “Released Parties”) from and against any and all claims, actions, demands, rights, causes of action, losses, liabilities, costs and expenses, including attorneys’ fees (“Claims”), arising from or in connection with any medical or dental aid rendered to the Camper, including any Claims arising out of the passive or active negligence or any other act or omission by the Released Parties; provided, however, that this release does not apply to liability for gross negligence, willful injury, or fraud.  I further agree to indemnify, defend, and hold the Released Parties harmless from and against (i) any claim by a medical or dental care provider or insurance coverage provider for the cost of medical or dental care provided to the Camper and (ii) any medical or dental bills paid by a Released Party on the Camper’s and/or my behalf.

I give permission for Camp staff to administer the following Over-the-Counter (OTC) medications and treatments consistent with medication directions.

  • Antihistamines
  • Antacid / Digestive drugs
  • Bug repellent
  • Decongestants
  • Eye drops
  • Pain relievers (Ibuprofen, Tylenol)
  • Sunscreen (lotion and spray)
  • Topical ointments or powders
  • Throat lozenges
INITIAL TO AUTHORIZE MEDICAL CARE

RELEASE OF LIABILITY AND INDEMNITY

THIS IS A RELEASE. BY SIGNING BELOW, YOU AND YOUR CHILD WILL WAIVE CERTAIN LEGAL
RIGHTS, INCLUDING THE RIGHT TO SUE. PLEASE READ IT CAREFULLY.

 

In consideration of the Camper participating in the Camp and its related activities, and as a condition thereof, I am signing this Release of Liability and Indemnity (this “Release”) on behalf of myself and the Camper. This Release is made in favor of USBSA, LLC, the entity operating the Camp, and the owner of the facility at which the Camp is operated (and their respective directors, officers, employees, officials, affiliates, sponsors, hosts, agents, assigns, subsidiaries, owners, partners, and joint venturers) (collectively, the “Released Parties”).

On behalf of myself and the Camper, I acknowledge and agree that:

  1. The risk of injury and/or loss from participating in Camp activities is always present due to the
    nature of the Camp, regardless of the care used, the skill or experience possessed, or the precautions taken by me, the Camper or anyone else, including any of the Released Parties. I am aware that participation in the Camp can cause physical and/or psychological injury, including, but not limited to, serious permanent bodily injury, paralysis, illness and/or death to the Camper or others, and/or damage to my, the Camper’s or others’ belongings. The Camper and I voluntarily elect, with knowledge of the risks involved, for the Camper to participate in the Camp.
  2. Participating in the Camp may expose the Camper to contagious diseases, such as, for example, coronavirus (COVID-19), influenza, and the common cold. These diseases spread easily through person-to-person contact, and may be spread by persons who are not exhibiting any symptoms. These diseases can lead to severe illness, personal injury, permanent disability, and death. Participating in the Camp increases the risk of becoming infected and/or ill. I acknowledge and agree that such risks are part of the risks and hazards that the Camper and I assume and release as set forth in this Release.
  3. I knowingly and freely accept and assume all risks, damages, and hazards associated, directly or
    indirectly, with the Camper’s participation in the Camp, whether known or unknown, whether caused by the action, inaction, or active or passive negligence of me, any of the other Released Parties, or therwise.
  4. I agree not to make a claim against or sue the Released Parties for, and I release, forever
    discharge, and will hold harmless the Released Parties, and each of them, from and against any and all claims, actions, demands, rights, causes of action, losses, liabilities, costs and expenses, including attorneys’ fees, arising from or in connection with any injury, disability, illness, death, or loss or damage to person or property that may be sustained or suffered by me, the Camper, or by any other person as a direct or indirect consequence of the Camper’s participation in the Camp, whether caused by the action, inaction or active or passive negligence of me, the Camper, any of the Released Parties, any third parties, or otherwise; provided, however, that this Release does not apply to liability for gross negligence, willful
    injury or fraud.
  5. I hereby agree to indemnify, defend and hold harmless the Released Parties, and each of them,
    from and against any and all losses, damages, liabilities, judgments, penalties, fines, costs and expenses, including attorneys’ fees, arising out of or in connection with any third party claim that arises out of or relates to the Camper’s participation in or attendance at the Camp. I understand and agree that I am responsible for any and all damages, losses, and expenses incurred by a Released Party arising out of or related to the Camper’s conduct.
  6. If I have any concerns regarding the Camper’s readiness for participation in the Camp and/or the Camp itself, I will remove the Camper from participation and bring such concerns to the attention of the Camp staff immediately.
  7. If any term or provision of this Release is determined to be illegal, unenforceable, or invalid in
    whole or in part for any reason, such provision shall not affect the legality, enforceability, or validity of any other provision of this Release and such provision shall be reformed and construed so that it will be legal, enforceable, and valid to the maximum extent permitted by law. This Release will survive the completion of the Camper’s participation in the Camp and will continue in full force and effect thereafter.
  8. I have read this Release carefully and fully understand all its terms and provisions. I have
    knowingly and voluntarily agreed to this Release understanding the risks to me and the Camper and have done so of my own free will, without relying on any statement or representation of any of the Released Parties. I understand that this Release is the entire agreement between me and the Released Parties with respect to the subject matter hereof and that that this Release cannot be modified or changed in any way by oral statements by any of the Released Parties or by the Camper or me. I understand that, in the event of any litigation against the Released Parties, this Release may be raised as a defense and bar to, and as a waiver and release of, legal rights that might otherwise be asserted by me, the Camper, or any of my or the Camper’s heirs, assigns, personal representatives or survivors.
Clear Signature
I acknowledge that I have carefully read the above Release of Liability and Indemnity, and that I understand its contents. By providing my initials next to this paragraph, I hereby agree to the Release of Liability and Indemnity.

MEDIA RELEASE

 

I HAVE READ THE INFORMATION PACKET AND FULLY UNDERSTAND OUR OBLIGATIONS STATED THEREIN AND ALSO THE RIGHTS OF USBSA, LLC (USBSA), AND HERBY AGREE TO ACT IN ACCORDANCE. For good and adequate consideration, which I acknowledge I have received, I hereby grant, release, and quit claim to USBSA royalty free the right and authority to use, reproduce, and distribute, quoted material, my child’s photograph, likeness, recorded voice, or videotaped filmed appearances (the "Materials") for promotional and advertising purposes as USBSA in its sole discretion will deem appropriate.

The undersigned further expressly agrees that the attached waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Clear Signature

AGREEMENT TO ARBITRATE DISPUTES

IN THE EVENT OF ANY DISPUTE PERTAINING TO ANY PROVISION OF THIS AGREEMENT, OR PERTAINING TO THE SERVICES RENDERED PURSUANT TO THIS AGREEMENT, OR IN ANY WAY RELATED TO ATTENDANCE AT THIS CAMP, INCLUDING ANY CLAIM FOR PERSONAL INJURY OR OTHER LOSS, INCLUDING ANY CLAIM AGAINST USBSA, USSC, THE ENTITY OPERATING THE CAMP AND THEIR DIRECTORS, OFFICERS, OFFICIALS, AFFILIATES, EMPLOYEES, SPONSORS, HOSTS, OR AGENTS, AND ALL SUBSIDIARIES, OWNERS, PARTNERS, JOINT VENTURERS, OFFICIALS, EMPLOYEES, OR AGENTS OF THE CAMP, OR OF ANY FOREGOING ENTITY, OR OF THE HOST FACILITY, SPONSOR OR INSTITUTION. EACH PARTY HERETO AGREES TO SUBMIT TO BINDING ARBITRATION TO RESOLVE SUCH DISPUTES, BY CLAIM FILED, BEFORE JAMS IN SAN FRANCISCO, CALIFORNIA, TO BE ARBITRATED HERE OR SUCH OTHER VENUE AS DEEMED APPROPRIATE BY THE JAMS ARBITRATOR, SUCH ARBITRATION TO PROCEED UNDER THE JAMS RULES. In the event either party to this agreement incurs any expense as a result of the other party’s failure to comply with any provision of this agreement, the non-complying party shall be liable for reimbursement of any and all such expenses or attorney fees directly or indirectly related to failure to comply. In the event any legal action or proceeding occurs which is in any manner related to or pertaining to this agreement, attempting to challenge in a non-arbitral forum such as a court of law the validity or application of this agreement, the party who substantially prevails in that court or non-arbitral proceeding shall be entitled to receive reasonable costs of such action or proceeding including attorney’s fees. In the arbitration itself, each party shall bear its own attorneys’ fees. The following disclosures are intended to help you thoroughly understand the significance of agreeing to arbitrate any controversy, or claim, or issue in any controversy or claim which may arise between the undersigned client and the attorney:

  • A) ARBITRATION SHALL BE FINAL AND BINDING ON THE PARTIES. B) THE PARTIES HERETO ARE WAIVING THEIR RIGHT TO SEEK REMEDIES IN COURT, INCLUDING THE RIGHT TO JURY TRIAL. C) PRE-ARBITRATION DISCOVERY IS GENERALLY MORE LIMITED THAN AND DIFFERENT FROM COURT PROCEEDINGS. D) THE ARBITRATOR’S (S) AWARD IS NOT REQUIRED TO INCLUDE FACTUAL FINDINGS OR LEGAL REASONING AND ANY PARTY’S RIGHT TO APPEAL OR TO SEEK MODIFICATION OF RULINGS BY THE ARBITRATOR (S) IS STRICTLY LIMITED. E) THE ARBITRATOR OR PANEL OF ARBITRATORS WILL TYPICALLY INCLUDE AN ATTORNEY OR JUDGE, ACTIVE OR RETIRED.

BY SIGNING BELOW, YOU ARE SIGNIFYING UNDERSTANDING AND ACCEPTANCE OF THE PROVISIONS OF THIS AGREEMENT.

I hereby certify that the above-mentioned participant is in good health and fully able to participate in all activities of the Camp. By signing below, I am stating that I am also aware of and accept the risk inherent in the program activity. By signing below, I agree as well to hold harmless and indemnify USBSA and USSC, their officers, directors, owners, officials, affiliates, agents and employees, and all subsidiaries from any and all liability, loss, damages, costs, refunds or expenses which are sustained, incurred or required out of the actions of my dependent in the course of the camp.

Clear Signature