Participant Name *

First Name

Last Name

Date of Birth *

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Parent/Guardian Name *

First Name

Last Name

Primary Phone *

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Primary Emergency Contact *

First & Last Name

First Name

Last Name

Emergency Contact Phone *

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Participation Agreement, Release, and Acknowledgement of Risk *

In consideration of the services of Fort Atkinson Boys’ Basketball Association, their members, agents, officers, volunteers, participants, employees, and all other persons or entities acting in capacity on their behalf (hereinafter collectively referred to as “FBBA”), I do hereby agree to release and discharge FBBA, on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows: I acknowledge that the game of basketball entails known and unanticipated risks which could result in physical or emotional injury, paralysis, death or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. The risks include, among other things: Collision with fans and other participants, the walls or other fixed objects; falling down; my own equipment failure or the failure of other’s equipment; my own or other’s negligence; objects or conditions on the gym floor surface that may cause me to fall; break bones; sprains; head, neck and back injuries; abrasions; and bruises or even death. Furthermore, FBBA volunteers have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant’s fitness, abilities or limitations. They may give inadequate warnings or instructions, and the equipment being used might malfunction. I expressly agree and promise to accept and assume all of the risk in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks. I hereby voluntarily release, forever discharge, and agree to indemnity and hold harmless FBBA from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of FBBA and Fort Atkinson School District and St. Joe’s Parish’s equipment or facilities, including such claims which allege negligent acts or omission of FBBA. Should FBBA or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnity and hold harmless for all such fees and costs. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage to myself. I further certify that I have no medical or physical conditions which could interfere with my safety in this activity, or else I am willing to assume – and bear the costs – of all risks that may be created, directly or indirectly, by any such condition. In the event that I file a lawsuit against FBBA, I agree to do so solely in the state of Wisconsin, and I further agree that the substantive law of that state shall apply in this action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portion shall remain in full force and effect. By checking the box below, I agree that if my child is hurt by or damages property during their participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against FBBA on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms. In consideration of my son/daughter, named above, being permitted by me to participate in FBBA activities and to use its equipment and facilities, I agree to the terms set forth above, on behalf of my son/daughter and individually, and further agree to indemnify and hold harmless from any and all Claims which are brought by, or on behalf of my son/daughter, and which are in any way connected with such use or participation by my son/daughter. I, parent/guardian of player, give the Fort Atkinson Boys Basketball Association (FBBA) including all representatives, coaches, and volunteers permission to give all necessary medical attention deemed necessary by authorized medical personnel. Electronic Signature:

I/We have read, understand and agree to comply with the Participant Agreement, Release, and Acknowledgment of Risk as outlined above.

HEADS UP Concussion Waiver *

This sheet has information to help protect your children or teens from concussion or other serious brain injury. Use this information at your children’s or teens’ games and practices to learn how to spot a concussion and what to do if a concussion occurs. WHAT IS A CONCUSSION? A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move quickly back and forth. This fast movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging the brain cells. HOW CAN I HELP KEEP MY CHILDREN OR TEENS SAFE? Sports are a great way for children and teens to stay healthy and can help them do well in school. To help lower your children’s or teens’ chances of getting a concussion or other serious brain injury, you should: - Help create a culture of safety for the team. - Work with their coach to teach ways to lower the chances of getting a concussion. - Talk with your children or teens about concussion and ask if they have concerns about reporting a concussion. Talk with them about their concerns; emphasize the importance of reporting concussions and taking time to recover from one. - Ensure that they follow their coach’s rules for safety and the rules of the sport. - Tell your children or teens that you expect them to practice good sportsmanship at all times. - When appropriate for the sport or activity, teach your children or teens that they must wear a helmet to lower the chances of the most serious types of brain or head injury. However, there is no “concussion-proof” helmet. So, even with a helmet, it is important for children and teens to avoid hits to the head. HOW CAN I SPOT A POSSIBLE CONCUSSION? Children and teens who show or report one or more of the signs and symptoms listed below—or simply say they just “don’t feel right” after a bump, blow, or jolt to the head or body—may have a concussion or other serious brain injury. Signs Observed by Parents or Coaches - Appears dazed or stunned. - Forgets an instruction, is confused about an assignment or position, or is unsure of the game, score, or opponent. - Moves clumsily. - Answers questions slowly. - Loses consciousness (even briefly). - Shows mood, behavior, or personality changes. - Can’t recall events prior to or after a hit or fall. Symptoms Reported by Children and Teens - Headache or “pressure” in head. - Nausea or vomiting. - Balance problems or dizziness, or double or blurry vision. - Bothered by light or noise. - Feeling sluggish, hazy, foggy, or groggy. - Confusion, or concentration or memory problems. - Just not “feeling right,” or “feeling down.” Talk with your children and teens about concussion. Tell them to report their concussion symptoms to you and their coach right away. Some children and teens think concussions aren’t serious or worry that if they report a concussion they will lose their position on the team or look weak. Be sure to remind them that it’s better to miss one game than the whole season. Concussions affect each child and teen differently. While most children and teens with a concussion feel better within a couple of weeks, some will have symptoms for months or longer. Talk with your children’s or teens’ health care provider if their concussion symptoms do not go away or if they get worse after they return to their regular activities. WHAT ARE SOME MORE SERIOUS DANGER SIGNS TO LOOK OUT FOR? In rare cases, a dangerous collection of blood (hematoma) may form on the brain after a bump, blow, or jolt to the head or body and can squeeze the brain against the skull. Call 9-1-1 or take your child or teen to the emergency department right away if, after a bump, blow, or jolt to the head or body, he or she has one or more of these danger signs: - One pupil larger than the other. - Drowsiness or inability to wake up. - A headache that gets worse and does not go away. - Slurred speech, weakness, numbness, or decreased coordination. - Repeated vomiting or nausea, convulsions or seizures (shaking or twitching). - Unusual behavior, increased confusion, restlessness, or agitation. - Loss of consciousness (passed out/knocked out). Even a brief loss of consciousness should be taken seriously. Children and teens who continue to play while having concussion symptoms or who return to play too soon—while the brain is still healing— have a greater chance of getting another concussion. A repeat concussion that occurs while the brain is still healing from the rst injury can be very serious and can a ect a child or teen for a lifetime. It can even be fatal. What Should I Do If My Child or Teen Has a Possible Concussion? As a parent, if you think your child or teen may have a concussion, you should: 1) Remove your child or teen from play. 2) Keep your child or teen out of play the day of the injury. Your child or teen should be seen by a health care provider and only return to play with permission from a health care provider who is experienced in evaluating for concussion. 3) Ask your child’s or teen’s health care provider for written instructions on helping your child or teen return to school. You can give the instructions to your child’s or teen’s school nurse and teacher(s) and return-to-play instructions to the coach and/or athletic trainer. Do not try to judge the severity of the injury yourself. Only a health care provider should assess a child or teen for a possible concussion. Concussion signs and symptoms often show up soon after the injury. But you may not know how serious the concussion is at rst, and some symptoms may not show up for hours or days. The brain needs time to heal after a concussion. A child’s or teen’s return to school and sports should be a gradual process that is carefully managed and monitored by a health care provider. To learn more, go to www.cdc.gov/HEADSUP Electronic Signature:

Participant Agreement: I learned about concussion and talked with my parent or coach about what to do if I have a concussion or other serious brain injury

Parent / Guardian Agreement: I have read this fact sheet for parents on concussion with my child or teen and talked about what to do if they have a concussion or other serious brain injury.

COVID-19 Policy *

By signing below, I expressly agree and understand that my child is participating at their own risk to engage in the following activities: Basketball. I understand the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization (WHO). Further, I acknowledge that COVID-19 cases have been confirmed in Jefferson County, Wisconsin and surrounding counties. In accordance with guidance issued by the WHO, the United States Centers for Disease Control and Prevention (CDC), and the Wisconsin Department of Health Services (WDHS), for slowing the transmission of COVID-19, I hereby agree, represent, and warrant that I shall not enter a basketball facility and engage in the foregoing activities within 14 days after (i) returning from highly impacted areas subject to a CDC Level 3 Travel Health Notice, (ii) exposure to any person returning from areas subject to a CDC Level 3 Travel Health Notice, or (iii) exposure to any person who has a suspected or confirmed case of COVID-19. I agree that they are aware of the CDC Travel Health Notices list (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html) and agree to check this list prior to signing this waiver. I hereby agree, represent, and warrant to not enter a basketball facility if I (i) experience symptoms of COVID-19, including, without limitation, fever, cough, or shortness of breath, or (ii) have a suspected or diagnosed/confirmed case of COVID-19. The Fort Atkinson Boys Basketball Association has taken reasonable steps to implement recommended guidance and protocols issued by Public Health Agencies for slowing the transmission of COVID-19, including, without limitation, the restrictions set forth above. I understand the inherent dangers for exposure to COVID-19 and other injuries while engaged in the foregoing activities which could result in quarantine requirements, serious illness, disability, and/or death and hereby assumes full responsibility for, and risk of, illness, bodily injury, or death. Having read and understood the above warning, I recognize the importance of reviewing and following the guidance issued by the WHO, CDC, and WDHS, as well as the FBBA policies and procedures related to same. By signing this agreement, I agree to be responsible for personal safety and hygiene while engaged in the foregoing activities and abide by FBBA rules and procedures related to social distancing and use of personal protective equipment (PPE), including, but not limited to face masks or shields. I further agree to hold the Fort Atkinson Boys Basketball Association, its volunteers and any and all persons or entities holding thereunder, including any and all policies of insurance, harmless from any and all claims, suits, obligations or other liabilities which arise or may arise out of the my engagement in the aforementioned activities. Further, I agree to indemnify any of the aforementioned persons and/or entities to the extent of any damage claims, including attorney fees, which arise or may arise out of my activities. Electronic Signature:

I/We have read, understand and agree to comply with the COVID-19 Policy outlined above.