Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Athlete Information and Consent Building Strength, Confidence, and Intellect. Question Title * 1. ATHLETE INFORMATION Athlete name/nickname: Current Age/Height/Weight: Has athlete grown more than 4 inches in past 6 months? Is athlete LHP or RHP: School athlete attends: Name of responsible party for athlete under 18: Address/City/State/Zip: Contact phone: Contact email: Do you prefer text messages or email? Emergency contact name & phone: Which teams has your athlete played on this past year? Do you have space in your backyard to play catch? How did you hear about Pitch In The Zone? (please be as specific as possible) OK Question Title * 2. ATHLETE HEALTH HISTORY What sports does athlete play? What is athlete's primary sport? What is(are) athlete's primary position(s)? How many months out of a calendar year does athlete play primary sport? When did athlete last pitch in a competitive game? Does athlete currently have any injuries? Y/N Is athlete recovering from any injuries? Y/N Describe athlete's current workout routine for his/her sport: Describe how athlete takes care of throwing arm: Has athlete worked with pitching coach before? If yes, please name: Athlete's Personal Goals for working with Hawk: Parent/Guardian Goals for working with Hawk: Describe athlete's sleeping behavior: Describe athlete's daily diet: How does athlete hydrate? Anything else I should know? OK Question Title * 3. •CANCELLATIONS AND NO SHOWS: as a courtesy to Thomas Jacquez, I appreciate all cancellations be made 24 hours in advance. There is an hourly training session fee for No-Shows or cancellations made less than 24 hours. •ATHLETE VIDEO AND ARM HEALTH ASSESSMENT is valid for three months. If athlete is continues to work with Thomas Jacquez, athlete agrees to maintain optimal arm health and fitness. Inactivity of your session purchase will result in loss of all remaining workouts.•PAYMENT: Payment is due prior to beginning assessment in the form of cash, check payable to Thomas Jacquez, PayPal, or Venmo. •CONSENT: To the best of my knowledge, the above information is complete and correct. I hereby waive and release Thomas Jacquez from any and all liability for any activity. I understand that it is my responsibility to inform Thomas Jacquez if my athlete ever has a change in health. I understand that each event participant is required to have his or her own medical and accident insurance. I, parent or official guardian grant permission to Thomas Jacquez to take and use: photographs and/or digital images of my athlete for use in news releases and/or materials as follows: printed publications or materials, electronic publications, or web sites. This consent will end when athlete has completed training sessions with Thomas Jacquez. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child and I may be exposed to or infected by COVID-19 by visiting and/or attending/participating in events; 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 SLU may result from the actions, omissions, or negligence of myself and others, including, but not limited to, SLU employees, independent contractors, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child 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 may experience or incur in connection with my child’s attendance at SLU or participation in SLU programming (“Claims”). On my behalf, and on behalf of my child, I hereby release, covenant not to sue, discharge, and hold harmless SLU, its employees, 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 SLU, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any SLU program. I agree and consent I agree and consent OK Question Title * 4. Electronic Signature of Athlete, Athlete Parent, Guardian or Personal Representative Athlete, Athlete Parent, Guardian or Personal Representative's Name: Date: OK WELCOME TO PITCH IN THE ZONE!