Important


This form must be completed on the same day, each day, before a player can be admitted into the ice session.

If any of these checkboxes are left unchecked, please stay home until you have been tested and cleared to safely return to group activities by a medical professional.

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Power Skating 100 (“PS 100”) has put in place preventative measures to reduce the spread of COVID-19; however, PS 100 cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending PS 100 could increase your risk and your child(ren)’s risk of contracting COVID-19.

I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending PS 100 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 PS 100 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, PS 100 employees, guest coaches, volunteers, and program participants and their families.

I attest that:

  1. - I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, taste or smell.

  2. - I have not traveled internationally within the last 14 days.

  3. - I have not traveled to a highly impacted area within the U.S. in the last 14 days.

  4. - I do not believe that I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.

  5. - I have not been diagnosed with Coronavirus/COVID or local public health authorities.

  6. - I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID -19.

  7. - I will abide by all verbal and written instructions given to me by PS 100 employees and coaches as well as ice arena staff.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at PS 100 or participation in PS 100 programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless PS 100, its employees, guest coaches, 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 PS 100, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any PS 100 program or activity.

I grant permission to Power Skating 100, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child, myself, and members of my family while at a Power Skating 100 event for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium by Power Skating 100. I hereby release Power Skating 100 and its legal representatives from liability for any violation or claims relating to said images or video.

Furthermore, I grant permission to use the statements of my child, myself, or my family members given during an interview or evaluation with or without my name for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.

I understand that this document is written to be as broad and inclusive as legally permitted. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I have read this document, and I am agreeing to it freely. No other representations concerning the legal effect of this document have been made to me.