Shen Fall Brawl Waiver
By submitting the following form, you agree to all the terms and conditions included within.
Player Name *
Your answer
Program/Team *
Player has an Active US Lacrosse Membership? *
A US Lacrosse membership is required to participate. If you do not have one you can register at www.uslacrosse.org.
Required
Player DOB *
MM/DD/YYYY
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone# *
Your answer
I am the parent/legal-guardian of the “Player” who has my permission to participate in the lacrosse program of the Shenendehowa Lacrosse Club, Clifton Park, New York, during all, or part, of the 2017 calendar year. I know that lacrosse is a contact sport that is inherently dangerous and involves risks of injury or even death. Furthermore, I acknowledge that there are ever-present risks in life generally and that during my child’s involvement in the Fall Brawl Lacrosse Tournament, there will be such risk. I knowingly and voluntarily assume these risks, and hereby release and hold harmless Shenendehowa Lacrosse Club, its board members, and all of its coaches and agents, representatives, and assigns, from all liability, claims, rights or causes of action which may accrue as a result of personal injury or property loss or damage sustained by Player arising out of, or as a consequence of, Player’s participation in the Fall Brawl Lacrosse Tournament. *
Required
I hereby authorize Shenendehowa Lacrosse personnel and coaches to authorize the performance of emergency treatment for children who incur injury or become ill, whose parents or guardians cannot be reached through reasonable efforts under the circumstances. *
Required
The following are facts concerning the Player’s medical history including allergies, medications being taken, medications causing an allergic reaction, and any physical impairment or condition about which a physician should be alerted:
Your answer
As a parent/guardian, I authorize the treatment of my child ("Player") by a qualified and licensed medical professional, in the event of injury or sickness for which medical and/or surgical treatment is deemed appropriate by a qualified and licensed medical professional. This release is effective during any period of time in which my child is participating in the Fall Brawl Lacrosse Tournament during the 2017 calendar year. I also hereby acknowledge my full and sole responsibility for payment of fees or costs for any treatment that my child receives pursuant to this Consent. *
Required
Alternate Contact Name & Phone# *
Your answer
Family Doctor Name & Phone# *
Your answer
Insurance Company Name & Policy# *
Example: CDPHP - 123456789
Your answer
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