Black Bear Free Clinic to Support Hurricane Harvey Relief Fund
Use this form to sign up for Black Bear's Free Clinic that will sponsor the American Red Cross's help of affected towns hit by hurricane Harvey. All donations collected at the clinic will go to the American Red Cross.
Email address
Parent/Guardian Name (Include First and Last)
Your answer
Name of Minor/Participant (Include First and Last)
Your answer
What is the minor/participant's graduation year?
What is the minor/participant's lacrosse position?
Confirm Email Address
Your answer
Emergency Contact Number
Your answer
Minor/Participant's US Lacrosse Number
Use this link to look up or sign up for a US Lacrosse Number: https://www.uslacrosse.org/membership
Your answer
MEDICAL AUTHORIZATION
I represent and warrant that I am over 18 years of age and have the legal authority and capacity to make binding legal decisions for the minor child ("Participant") that I am registering for this event. I understand that Participant will be participating in lacrosse related activities and/or events directed, sponsored, recomended or otherwise approved by Black Bear Lax, LLC (collecticely "BBX Events") and I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis, and even death, as well as other damages and losses, associated with participation in a lacrosse event or BBX Events. I understand that BBX Events will consist of physical activities, drills, training and games which may pose a risk of injury to the Participant, and I hereby knowingly and voluntarily assume on behalf of the Participant all risks and responsibilities for any such injury. I agree that I will be financially responsible for any medical attention needed by Participant during the BBX Event or resulting from any injury received at any BBX Events. My medical insurance shall be the primary medical insurance coverage for any medical treatment received by Participant.
Required
Photo Release
I represent that I am over 18 years of age and have the legal authority and capacity to make binding legal decisions for the minor child ("Participant") that I am registering for this event. I understand that Participant will be participating in lacrosse related activities and/or events directed, sponsored, recomended or otherwise approved by Black Bear Lax, LLC (collecticely "BBX Events"). I understand that Black Bear Lax, LLC retains the right to use for publicity and advertising purposes, photographs of individuals participating in BBX Events and do hereby consent to the use of such photos for such purposes by Black Bear Lax, LLC.
Required
LIABILITY WAIVER
I represent and warrant that I am over 18 years of age and have the legal authority and capacity to make binding legal decisions for the minor child ("Participant") that I am registering for this event. I understand that Participant will be participating in lacrosse related activities and/or events directed, sponsored, recomended or otherwise approved by Black Bear Lax, LLC (collecticely "BBX Events") and I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis, and even death, as well as other damages and losses, associated with participation in a lacrosse event or BBX Events. I agree on behalf of the Participant, myself, my heirs and personal representatives, to fully release, defend, indemnify and hold harmless Black Bear Lax, LLC, and its members, officers, directors, employees and agents from any damages, costs, or liability whatsoever for any injury, illness or harm related to Participant's participation in a lacrosse event or BBX Events. I agree futher on behalf of the Participant, myself, my heirs and personal representatives, to fully release, defend, indemnify and hold harmless the host(s), sponsors or facilities owner(s) and the members, officers, directors, employees and agents, of these organizations from any damages, costs, or liability whatsoever for any injury, illness or harm related to Participant's participation in a lacrosse event or BBX Events.
Required
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