National Coaching Standards Domain 2
Domain 2: Safety and Injury Prevention
Standard 5: Prevent Injuries by providing safe facilities
Benchmark: modify plans for practice and competition after assessing potentially unsafe conditions that may exist
Waiver and Release of Liability
I _____________________ (participant name printed) understand and acknowledge the dangers associated with athletic training through DALZELL COACHING. It is my sole responsibility to be cleared by a physician before physical activity and I take all credit for any medical consequences of my training. I also understand that the sports of swimming, cycling, and running can cause serious injury and in some cases DEATH. I clear DALZELL COACHING of any responsibility in a resulting injury or death even if caused by negligence. I volunteer myself to participate in any athletic training, racing, conversation, or mental skills training and assume all risks involved. By completing this waiver, I acknowledge all risks and take full responsibility for my actions.
Furthermore, if serious injury or death happens as a result of my training with DALZELL COACHING, I remove them from all responsibility as well as take the blame on behalf of a third party. There should be in no way, shape, or form any doubt that I openly volunteered for this partnership and assume all risks of the activities involved. I acknowledge that these activities are strenuous cardiovascular exercise, strenuous physical activity as well as mentally taxing. At the end of the day, it is up to I ____________________________ (participant name printed) to take full responsibility of my consequences even if that means INJURY OR DEATH. I hereby openly volunteer myself for athletic training, swimming, cycling, running, weight lifting, mental training and walking under DALZELL COACHING and take full responsibility for any losses both financially and medically that may occur.
I __________________________ (participant name printed) have read and agree to the terms above
___________________________ Participant Signature _______________ Date
___________________________ Witness Signature ________________Date
Domain 2: Safety and Injury Prevention
Standard 8: Identify physical conditions that predispose athletes to injuries
Benchmark: Ensure that clearance for athletes to participate fully or partially in practices or contests is given by a parent, guardian, and/or medical professional
Dalzell Coaching LLC
Physical Activity Readiness Questionnaire
Name: Date:
Phone: Age:
This form has been designed to help identify whether or not you should consult your personal physician before beginning an exercise program.
Please read the following questions carefully and check the appropriate answer. Answer the questions to the best of your ability
Yes No
____ ____ 1. Have you ever had a stroke, heart attack, or heart surgery?
____ ____ 2. Do you frequently suffer from chest pain?
____ ____ 3. Have you ever been told that you have a heart or blood vessel problem?
____ ____ 4. Have you ever been told that you have a bone, joint or muscle problem that could be made worse by physical activity?
____ ____ 5. Do you have any major illnesses that could be made worse by physical activity?
____ ____ 6. Are you over the age or 45 and just beginning an exercise program?
____ ____ 7. Do you have a blood pressure greater than 140/90 or cholesterol higher than 240 mg/dl?
If you answered “Yes” to any of the above questions, it is recommended that you receive medical clearance from your personal physician before participating in any physical activity.
Standard 5: Prevent Injuries by providing safe facilities
Benchmark: modify plans for practice and competition after assessing potentially unsafe conditions that may exist
Waiver and Release of Liability
I _____________________ (participant name printed) understand and acknowledge the dangers associated with athletic training through DALZELL COACHING. It is my sole responsibility to be cleared by a physician before physical activity and I take all credit for any medical consequences of my training. I also understand that the sports of swimming, cycling, and running can cause serious injury and in some cases DEATH. I clear DALZELL COACHING of any responsibility in a resulting injury or death even if caused by negligence. I volunteer myself to participate in any athletic training, racing, conversation, or mental skills training and assume all risks involved. By completing this waiver, I acknowledge all risks and take full responsibility for my actions.
Furthermore, if serious injury or death happens as a result of my training with DALZELL COACHING, I remove them from all responsibility as well as take the blame on behalf of a third party. There should be in no way, shape, or form any doubt that I openly volunteered for this partnership and assume all risks of the activities involved. I acknowledge that these activities are strenuous cardiovascular exercise, strenuous physical activity as well as mentally taxing. At the end of the day, it is up to I ____________________________ (participant name printed) to take full responsibility of my consequences even if that means INJURY OR DEATH. I hereby openly volunteer myself for athletic training, swimming, cycling, running, weight lifting, mental training and walking under DALZELL COACHING and take full responsibility for any losses both financially and medically that may occur.
I __________________________ (participant name printed) have read and agree to the terms above
___________________________ Participant Signature _______________ Date
___________________________ Witness Signature ________________Date
Domain 2: Safety and Injury Prevention
Standard 8: Identify physical conditions that predispose athletes to injuries
Benchmark: Ensure that clearance for athletes to participate fully or partially in practices or contests is given by a parent, guardian, and/or medical professional
Dalzell Coaching LLC
Physical Activity Readiness Questionnaire
Name: Date:
Phone: Age:
This form has been designed to help identify whether or not you should consult your personal physician before beginning an exercise program.
Please read the following questions carefully and check the appropriate answer. Answer the questions to the best of your ability
Yes No
____ ____ 1. Have you ever had a stroke, heart attack, or heart surgery?
____ ____ 2. Do you frequently suffer from chest pain?
____ ____ 3. Have you ever been told that you have a heart or blood vessel problem?
____ ____ 4. Have you ever been told that you have a bone, joint or muscle problem that could be made worse by physical activity?
____ ____ 5. Do you have any major illnesses that could be made worse by physical activity?
____ ____ 6. Are you over the age or 45 and just beginning an exercise program?
____ ____ 7. Do you have a blood pressure greater than 140/90 or cholesterol higher than 240 mg/dl?
If you answered “Yes” to any of the above questions, it is recommended that you receive medical clearance from your personal physician before participating in any physical activity.
