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Please read and accept or decline the below:


Waiver - Informed Consent and Waiver Agreements for All Movement and Mindset  Programs

Please read the following waiver carefully.



Below you will find three Agreements:


  1. Sapphenix Movement Recreation and Competition Programs Informed Consent Agreement and Waiver and Release

  2. Concussion Informed Consent Agreement

  3. COVID 19 Informed Consent Agreement


As a condition of participation in a movement and mindset program you must review each agreement and indicate your consent for all three by using the electronic button at the end this document.  If you have questions or concerns, do not complete the agreements without speaking to Kimberly Beckles, CEO and Founder of The Sapphenix Movement Company Inc.


  1. Sapphenix Movement Recreation and Competition Programs Informed Consent, Waiver and Release


I acknowledge that certain RISKS of INJURY are inherent in participation in sports and recreation activities. These types of risks can include, but are not limited to physical injury such as slips, falls, fractures, cuts, concussions, collisions, contact with equipment, EFFECT of climatic conditions, accidents in transportation, damage or loss of personal sports equipment or other property, and any other manner of harm. I acknowledge that there may be specific risks associated with particular sports and recreation activities, and I acknowledge that I have had the opportunity to speak with a knowledgeable Sapphenix official (including but not limited to coaches) about such risks.  Further, where the nature of the risk warrants and a specific Consent form is used, it is included below and has also been agreed to by me.




I acknowledge that there may be RULES and REGULATIONS applicable to the sport or activity I wish to participate in, and that they are designed for enhancement of safety and protection of myself and other participants. I have informed myself of whether such RULES and REGULATIONS EXIST, AND IF THEY DO I undertake to abide by them.


I acknowledge that all activities require a level of FITNESS and HEALTH (physical, mental and emotional)


Note: If you have questions about the RELEVANT RISKS as they pertain to your sport or activity, the RULES AND REGULATIONS applicable to your sport or activity and/or the required level of FITNESS AND HEALTH as they pertain to you sport or activity, ensure that you speak to Kimberly Beckles, CEO and Founder of The Sapphenix Movement Company Inc., before you decide whether or not to provide Consent.


  1. Concussion Informed Consent, Waiver and Release



  • A concussion is a brain injury.

  • All concussions must be taken seriously.

  • Most concussions do not involve loss of consciousness, or “blacking out”.

  • Concussions can occur in any sport or recreational activity, across all levels of participation.

  • Recognition and proper management of concussions when they first occur can help prevent further injury or even death.


What is a concussion?


A concussion is a type of mild traumatic brain injury that occurs when an external force causes the brain to move quickly forwards, backwards, and/or rotationally inside the skull following a hit to the head or body. A concussion is caused by a blow to the head or body that causes the brain to move rapidly inside the skull. Even a “ding,” “getting your bell rung,” or what appears to be a mild jolt or blow to the head or body may cause the brain to shift or rotate suddenly within the skull. Concussions can also result from a fall or from players colliding with each other or with obstacles even if they do not directly hit their head. The potential for concussion is greatest in athletic environments where collisions are common. However, concussions can occur in any organized or unorganized sport or recreational activity and once the injury occurs, the brain is vulnerable to further injury and sensitive to any increased stress until it fully recovers. The symptoms of concussion are typically grouped into 4 categories: Physical (e.g., headache, nausea, sensitivity to light or sound), Cognitive/Thinking (e.g., attention, concentration, or “feeling slow”), Emotional (e.g., sadness, anxiety, and irritability), or Sleep Disturbance (e.g., inability to fall asleep, as well as sleep to much or too little). Concussion symptoms are dynamic. They do not always appear immediately after a hit and may change over time.


To help recognize a concussion, watch for the following two things:

  1. A forceful blow to the head or body that results in rapid movement of the head.

  2. Any change in an athlete’s behavior, thinking, or physical functioning.


The following are signs (i.e., what a teammate, coach, or medical personnel can observe) and symptoms (i.e., what an athlete may report) of concussion:


Signs - the affected person:

  • Appears dazed or stunned

  • Is confused about assignment or position, forgets sports plays

  • Is unsure of game, score or opponent

  • Moves clumsily

  • Answers questions slowly

  • Loses consciousness (event briefly)

  • Shows behaviour or personality changes

  • Cannot recall event prior to hit/contact


Symptoms – the affected person:

  • Feels slow or has slurred speech

  • Feels sluggish, hazy, foggy or groggy

  • Has a headache, feels pressure in the head, feels nauseas

  • Has balance problems or dizziness

  • Has double or blurry vision, is sensitive to light or sound

  • Has difficulty concentrating or remembering

  • Is confused or “just doesn’t feel right

  • Is sad, anxious and/or nervous


Participants who experience any of these signs, symptoms or behaviors following an observed or suspected blow to the head or body must not be allowed to participate in any further activity.  Further, the participant cannot return to activity unless cleared via an assessment performed by medical personnel and following prescribed ‘return to play’ protocols.


Signs and symptoms of concussion can last from several minutes, to days, weeks, months or even longer in some cases. Remember, one cannot see a concussion and some athletes may not experience and/or report symptoms until hours or even the next day after the injury.


A repeat concussion that occurs before the brain recovers from the first concussion – usually within a short period of time (hours, days or weeks) – can slow recovery or increase the likelihood of having long-term cognitive problems. Avoidance of second impacts is why it is critical to keep participants with known or suspected concussions from activity until they have been evaluated and received a medical release from a qualified health care professional.


ACTION PLAN - What should I do if I think I have a concussion?

  1. Immediately remove yourself from play and discontinue all physical activity.

  2. Tell your coach, a medical professional and or a family member/friend. Never ignore a bump or blow to the head even if you feel fine.

  3. Seek medical evaluation. A doctor or health care professional can tell you if you have a concussion and when you are OK to return to play. 

  4. Give yourself time to get better. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a second concussion. Additional hits during recovery may prolong concussion symptoms or make concussion symptoms worse. It is important to rest acutely after injury, followed by a graded progression of exertion/stress guided by a doctor or health care professional to return to play.


Please Note - If you have questions about concussion risks as they pertain to your sport, ensure that you speak to your coach or to Kimberly Beckles, CEO and Founder of The Sapphenix Movement Company Inc. before you decide whether or not to agree to provide Consent.


  1. COVID-19 Informed Consent Agreement


COVID 19 is a pandemic disease caused by the SARS-CoV-2 virus that is easily transmitted between people, and for which there is currently no cure. While COVID-19 is a mild illness in most cases, it is a severe illness sometimes causing death in a minority of cases, particularly in the elderly or people with pre-existing cardiovascular, respiratory, or metabolic health disorders.

Transmission of SARS-CoV-2 may occur by airborne virus and/or virus on touched surfaces.  The likelihood of transmission may be reduced by maintaining sufficient physical distance (2m) between people, frequent washing or disinfection of hands, avoiding touching of the face, and wearing of masks, but such measures cannot guarantee freedom from risk of transmission.

The prevalence of COVID-19 is high in many regions of the world, such that (at this time), any individuals who return to Canada from travel outside this country are required to isolate themselves for 14 days after return.

The Sapphenix Movement Company Inc. is taking and will take all reasonable precautions required or advised by public health authorities to reduce the likelihood of disease transmission in our facilities and programs; but some such risk still exists.

Included among the precautions taken by the company are health screening examinations or questionnaires (to reduce the effect of having symptomatic individuals participating in programs) and verification of attendance at programs (to permit contact tracing in the event of disease identification).

I agree that:

  1. I have read and fully understand the above statements about transmission of SARS-CoV-2, the risk of contracting COVID-19, its potential consequences, and measures taken to reduce these risks

  2. I will at all times conduct myself in a way that minimizes the risk of SARS-CoV-2 transmission, by complying with all regulations and requirements of federal, provincial and municipal public health authorities and the Sapphenix Movement in that regard. 

  3. I will complete all screening examinations, questionnaires, and verifications of attendance required by the Sapphenix Movement to permit participation in Sapphenix movement, sport and recreation programs.

By signing below, I understand, acknowledge and assume the inherent risks of exposure to SARS-CoV-2 and contraction of COVID-19, and contact or interaction with others who may have COVID-19 or may have been exposed to SARS-CoV-2. I assume the COVID-19 risks of participating in sport and recreation activities.


Please Note - If you have questions about COVID 19 risks as they pertain to your sport, ensure that you speak to Kimberly Beckles, CEO and Founder of The Sapphenix Movement Company Inc. before you decide whether or not to agree to provide Consent.




Having read, understood to and agreed to all of the above acknowledgements, warranty, waiver and release, I VOLUNTARILY CONSENT TO PARTICIPATE.  If I am registering a minor, I certify that I am the parent/guardian for that minor, and agree to the above on their behalf.


I WAIVE all rights that I, or my heirs, executors, administrators or assigns, have now or may have hereafter to claim damages, compensation, penalties or any other kind of remedy, financial or otherwise,  arising directly or indirectly from an injury,  loss or damage flowing from my PARTICIPATION, and I RELEASE the GOVERNING COUNCIL OF THE SAPPHENIX MOVEMENT COMPANY  and each of its governors, officers, employees, agents, and volunteers (the RELEASEES) from any liability, except, and only to the degree that such injury is caused by the NEGLIGENCE of the Sapphenix or any of the RELEASEES.



I acknowledge that I have read the above information regarding concussions and understand the risk of CONCUSSION associated with participation in sport and recreation activities.


I acknowledge that I have read the above information regarding concussions and understand the risk of CONCUSSION associated with participation in sport and recreation activities.

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