In consideration of being permitted to participate in Marquette University/Black Lax LLC Fall Clinic, I hereby release the Board of Regents, State of Wisconsin; Marquette University; Marquette University Lacrosse Program; and Black Lax LLC, their employees, volunteers, or agents from any and all liability or claims relating to any bodily injury or property damage that may be sustained by the participant while attending Fall Clinic and during transportation to and from the event. Marquette University and Black Lax LLC will only be responsible for bodily injury or property damage that results from the negligent acts or omissions of The University, its employees, volunteers, or agents in conjunction with this program. I hereby authorize and give my consent to the staff of the event to act on my behalf to secure medical treatment for the admin istration of all emergency medical, emergency surgical, and non-emergency medical treatment that may be necessary in connection with the participant’s participation in the event. I understand that if medical treatment is necessary, an attempt will be made to contact me. In the event that I cannot be reached, I hereby give consent to such treatment as deemed necessary by a licensed health care professional. I agree to assume all costs related to such treatment. I understand that I will be solely responsible for any medical or other charges in connection with attendance at this event. Such charges include, but are not limited to, deductibles, co - pays, co - insurance, out of network, out of state restrictions and any and all costs not covered by health insurance I authorize the disclosure of medical information to the insurance company listed below for the purpose of any claim. (Each participant must provide his/her own health insurance.) I hereby give my consent to use the likeness and/or name/identity of the above named participant for purposes of promotional materials or any other type of media produced and/or published by Marquette University and Black Lax LLC to promote or publicize future events. *
