Bingham Boys High School Lacrosse Registration Fall 2017

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For Bingham Boys Lacrosse Players Grades 9th-12th

Player's First Name *

Player's Last Name *

Player's Email Address *

Player Address *

Player Cell Phone Number *

High School? *

What High School do you or will you attend?

Grade? *

What grade are you in?

Player's Position *

What position do you usually play?

Attackman

Midfielder

Long Stick Middie (LSM)

Defensiveman

Goalie

FOGO (face off/get off)

Not sure

Required

Have you been diagnosed with a concussion? *

Yes

Required

If yes, how many times have you been diagnosed with a concussion?

Men's shorts size *

Be accurate! Shorts CANNOT be exchanged once they are ordered!!

Men's Small

Men's Medium

Men's Large

Men's XL

Men's Shooting T-shirt size

Be accurate! Shooting shirts CANNOT be exchanged once they are ordered!

Men's Small

Men's Medium

Men's Large

Men's XL

Men's XXL

Clear selection

U.S. Lacrosse Membership # *

Every player must have a U.S. Lacrosse Membership. U.S. Lacrosse Memberships are obtained online at www.uslacrosse.org

U.S. Lacrosse Exp Date *

Your U.S. Lacrosse Membership must be valid through 05/31/2016, if it expires before then renew at www.uslacrosse.org

Volunteer Hours *

All families are required to volunteer 10 hours/yr to avoid forfeit of the addition $150 paid with registration. What tasks are you willing to help with?

Field Set Up/Take Down

Hang Up/Take Down Banners

Score Table Help

Team Parent(s)

Game Photographer (willing to upload to team website)

Game Videographer (willing to upload to team website)

Pasta Party

Senior Night

Year End Banquet

Blake Strebel Alumni Game

Other:

Required

Primary Parent First Name *

Primary Parent Last Name *

Primary Parent Cell Phone Number *

Primary Parent Email *

Second Parent First Name

Second Parent Last Name

Second Parent Cell Phone Number

Second Parent Email

Additional Email

Other parent, guardian, grandparent, etc. who wants to receive Bingham Lacrosse information for this player.

Primary Health Insurance Carrier *

ID Number? *

Health Insurance Group, Policy or Member Identification #

BINGHAM HS LACROSSE ASSOCIATION WAIVER & MEDICAL RELEASE *

In consideration of my participation in Bingham HS Lacrosse and US Lacrosse, and my participation in any Bingham HS Lacrosse recognized or sponsored events (“Covered Events”), I agree to the following: 1. Waiver & Release: I am fully aware of and appreciate the risks, including the risks of catastrophic injury, paralysis, and even death, as well as other damages and losses associated with participation in a lacrosse event. In my capacity as parent or legal guardian of the Player, I understand these risks and my responsibility to notify the other parent or legal guardians of the Player, as well as the Player, of the risks involved with participating in the Covered Events and otherwise participating in the sport of lacrosse. I have made a conscious decision to allow the Player to participate. I agree that my health and accident insurance will be the primary insurance to cover any expenses for any injury to the Player. I understand and agree that Bingham HS Lacrosse Association, and its agents or representatives, is not the insurer of the Player’s conduct during the course of the League. TO THE FULLEST EXTENT PERMITTED BY LAW, I HEREBY RELEASE AND WAIVE AND COVENANT NOT TO SUE BINGHAM HS LACROSSE ASSOCIATION AND ITS MEMBERS, COACHES, DIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AGENTS AND REPRESENTATIVES (THE “RELEASED PARTIES”) WITH RESPECT TO ANY AND ALL LIABILITY AND CLAIMS WHATSOEVER ARISING OUT OF OR RELATED TO ANY LOSS, DAMAGE, OR INJURY, INCLUDING DEATH, THAT MAY BE SUSTAINED BY THE PLAYER ARISING OUT OF OR RELATED TO THE PLAYER’S PARTICIPATION IN THE COVERED EVENTS. 2. Medical Attention: I hereby give my consent to Bingham HS Lacrosse Association and the host organization of any Covered Event to provide, through a medical staff of its choice, customary medical/dental/athletic training attention, transportation and emergency services as warranted in the course of participation in Covered Events. 3. Readiness to Compete: My participant is physically and psychologically prepared to compete.

Yes, I (Parent) have read and agree to the above Bingham HS Lacrosse Association Waiver & Medical Release for my player's participation in the Bingham Lacrosse HS Spring 2017 Season.

Yes, I (Parent) have read and agree to the UHSLL Parent Contract

Yes, I (Parent) have read and agree to the Bingham Lacrosse Code of Conduct

Yes, I (Player) have read and agree to the UHSLL Boys Player Contract

Yes, I (Player) have read and agree to the Bingham Lacrosse Code of Conduct

Required

I certifiy that I (Parent or Player) am age 18 years or older *

Yes

Required

Electronic Signature of Parent *

First Name and Last Name (By signing form, you are also agreeing to the Parent Contract and Code of Conduct)

Electronic Signature of Player *

First Name and Last Name (By signing form, you are also agreeing to the Player Contract and Code of Conduct)

Submit

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