Dodgeball Registration Release

2025 Dodgeball Tournament Release Form

Please fill out the Liability/Accident Waiver and Release of Liability and Confidentiality Statement.

• Name
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  Date
  MM slash DD slash YYYY
• Name*
  First Last
• Email*
• Phone*
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• Liability/Accident Waiver and Release of Liability*
  • By checking this box, I verify that I am doing so voluntarily and, I acknowledge that there are inherent risks associated with participation in this program.
  Risks include, by way of example and not limitation, stress strain and pulled muscles and other soft tissue, broken bones, heart and related problems from exertion or stress, death from said exertion and I accept and assume the risks of injury or death from participating in this program. I agree to observe and obey all written and oral instructions by Serenity Lane staff or representatives and to follow basic safety protocol. I assume full responsibility for personal injury for the duration of my participation. I hold Serenity Lane harmless and release Serenity Lane from responsibility for any injury, loss, or damage from my use of Serenity Lane facilities, or while participating in any on-site or off-site activities, whether caused by the fault of myself or third parties. Additionally, I agree to pay for all damages to Serenity Lane facilities caused by my negligent, reckless, or willful actions.
  
  Regarding activities, I understand the following:
  
  It is my responsibility to notify the Serenity Lane activity supervisor of any physical problem which could threaten my physical safety. I will notify staff if I have any significant health problems that may be affected by exercise activity.
  
  I will communicate with staff if I become disoriented, strained, stressed, short of breath, or dizzy.
  
  Serenity Lane is not responsible for personal items that are lost, stolen, or damaged.
  
  Equipment must be handled with care, only used for its intended purpose, and any moveable Equipment must be returned to its proper place after use.
  
  Abusive or Provocative Language is prohibited. I will Respect other participants at all times.
  
  Equipment failure, breakage, safety concerns, or injuries must be reported to a Serenity Lane staff member promptly.
  
  
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• Confidentiality Statement*
  • I have read the confidentiality statement and agree to respect patient privacy
  Confidentiality Statement DO NOT VIOLATE OUR PATIENTS CONFIDENTIALITY
  
  Those who have sought treatment for Substance Use Disorders (SUDs) have their confidentiality protected by 42 CFR, Part 2. In some cases these regulations are more stringent than HIPAA.
  
  Confidentiality in this field is protected in two ways:
  1. All information identifying a person as having a Substance Use Disorder is confidential and may not be released without consent from the patient.
  2. All Protected Health Information (PHI), including demographic data that is created by Serenity Lane and relates to the patient’s medical or mental health, the services provided, and payment provided falls under the protection of HIPAA and may not be released without consent by the patient.
  
  Federal regulations (42 CRF Part 2) prohibits anyone from disclosing the identity of our patients without their written permission. Violations of confidentiality may be punishable under the law. If you see anyone you know or meet someone on these premises, you are required by law not to disclose the information to anyone. This regulation applies to everyone, no exceptions.
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