Boomerang - Individual Player Medical Release
Player's Information
Team Name *
Age Division *
Player's First Name *
Your answer
Player's Last Name *
Your answer
Player's Date of Birth *
Example: 10/22/1999 (month, day, year)
Your answer
Player's Position *
Required
Player's Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Player's E-Mail *
Your answer
Parent/Guardian Information
Parent's First Name *
Your answer
Parent's Last Name *
Your answer
Relationship to Player *
Your answer
Parent's E-Mail *
Your answer
Phone # *
Your answer
Secondary Parent's First Name *
Your answer
Secondary Parent's Last Name *
Your answer
Secondary Parent's Phone # *
Your answer
Secondary Parent's E-Mail *
Your answer
Emergency Contact Info
Emergency Contact's First name *
Your answer
Emergency Contact's Last Name *
Your answer
Phone # *
Your answer
Alternative Phone # *
Your answer
Insurance Carrier *
Your answer
Insurance Number *
Your answer
Policy Holder's Name *
Your answer
Preexisting Medical Conditions *
Required
Current Medications *
Required
Allergies *
Required
I authorize the staff of the tournament to use their best judgment in allowing my child to receive emergency medical or surgical treatment if necessary. I understand that every effort will be made to contact me prior to such action. (PLEASE BE ADVISED THAT IT IS IMPERATIVE THAT YOUR CHILD BE IN GOOD HEALTH WHEN ARRIVING AT TOURNAMENT. THE DUTIES OF TOURNAMENT PERSONNEL CANNOT INCLUDE PROVIDING MEDICAL CARE PERTAINING TO EXISTING INJURIES OR ILLNESSES AND WITH THE EXCEPTION OF EMERGENCY SITUATIONS.) I hereby: 1. certify that, to the best of my knowledge, the medical information is complete and correct. 2. agree to assume all risk of personal injury arising from participation in this tournament, understanding that this sport does involve the potential for injury. 3. agree not to hold the staff responsible for any injury sustained during tournament participation. 4. agree not to make any claims or demands against tournament staff or Boom Town Lacrosse, LLC for any injury sustained. 5. agree to allow the Tournament Director to use his/her judgment in obtaining necessary medical care, at the expense of the parent. 6. agree to accept any decisions made by the Tournament Director in terminating attendance due to unacceptable behavior. *
Waiver & Medical Release
I, the undersigned, hereby agree that I understand and accept the risks, including the risk of catastrophic injury, paralysis, and even death, as well as other losses and damages, associated with the game of lacrosse and with my child's participation in a lacrosse tournament and related events (“Event"). I certify that my child is in sufficiently good mental and physical condition to participate in the Event. I agree, on behalf of myself, my heirs, and personal representatives, that Boom Town Lacrosse, LLC, and respective parents, subsidiaries, affiliates, owners, members, directors, officers, agents, employees, volunteers and training staff (collectively the "Covered Parties") shall not be held liable for any injury, damage to personal property, loss of life or other loss or damage as a result of my child's participation in the Event and any activities relating to the Event or conducted by the Covered Parties. It is my specific intention that none of the Covered Parties shall have any liability whatsoever as a result of or in connection with my child's participation in this Event. I hereby waive any claims that I might have against any Covered Parties and release all Covered Parties from any such liability. I agree to indemnify the Covered Parties against any such claims. In addition, I hereby give my consent to Boom Town Lacrosse, its owners and operators and all other Covered Parties to provide, through medical staff of its choice, customary medical/athletic training attention, transportation and emergency medical services as warranted in the course of my child's participation in the Event. Notwithstanding the foregoing, I understand and agree that none of the Covered Parties have any obligation to provide any such medical/athletic training attention and the lack of any such medical/athletic training attention or the provision thereof on a voluntary basis shall be covered by the waiver and release set forth in this paragraph. I further authorize all Covered Parties to obtain necessary medical treatment for my child if he or she is deemed medically unfit by a medical professional and hereby, on my own behalf and on behalf of my child, release and hold harmless the Covered Parties in the exercise of this authority. I further understand and agree that I will be responsible for any and all medical and related bills that may be incurred on behalf of my child for any illness or injury that he or she may sustain during the Event and while traveling to and from the site for the Event, whether or not the Event actually occurs. I represent that any medication to which my child is allergic or medications that he or she is currently taking are listed below. I agree that my child shall bring medications which he or she is currently taking with him or her to the Event and that he or she shall consume the prescribed dosage for such medications. I further grant the Covered Parties and their respective successors and assign the perpetual worldwide and royalty-free rights to use, with the possibility of sale for the profit of the Covered Parties, my child's voice, photograph, and likeness, in any media related to my child's participation in this Event or any activities relating to the Event conducted by the Covered Parties including, without limitation, a videotape recording, without compensation to me, or my personal representatives, assigns, heirs, children, dependents, spouse and relatives. I also agree that contact information for both myself and my child may be provided to businesses that are contributing to the Event in a supporting role. Boom Town Lacrosse, LLC will use email addresses and phone numbers provided to relay important announcements and information about the event. You may also receive future communications from Boom Town Lacrosse, LLC pertaining to various events. I hereby acknowledge that I have carefully read this Liability Waiver and Release of Liability, that I fully understand its content, that I am over the age of 18 years, that I am the legal guardian of the participant, and that I am acknowledging this Liability Waiver and Release voluntarily and intend for it to be legally binding. Please enter in information below. All fields marked with an asterisk are mandatory. Your waiver & release will not be accepted if any mandatory field is left blank. *
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