Girls Blackhawks Spring 2021 Uniform Agreement
East Brunswick Blackhawks Girls Lacrosse
21 Civic Center Drive, #13
East Brunswick, NJ 08816
Email address *
Medical Authorization
I hereby give permission for (child’s name) ____________________________________________________, to participate in the East Brunswick Blackhawks Girls Lacrosse during the 2021 athletic season. I am aware that participating in youth lacrosse is a potentially hazardous activity. I assume all the risks associated with participating in the East Brunswick Blackhawks Girls Lacrosse. I understand the risk to my child includes a full range of injuries from minor to severe, and the result could be death, paralysis, or other serious permanent disabilities. I agree to accept these risks as a condition of my child’s participation.
Child's Name *
Child's Date of Birth *
Known Allergies or other pertinent medical information
Parent(s)/Guardian(s) Name(s) *
Parent(s)/Guardian(s) Email(s) *
Parent(s)/Guardian(s) Home Phone *
Parent(s)/Guardian(s) Cell(s) *
Emergency Contact - Name, Phone Number, Relationship *
Emergency Contact - Name, Phone Number, Relationship *
Health Insurance *
Policy Number *
Name of Physician and Phone Number *
RWJ or Saint Peter's *
I hereby give my consent, in the event all reasonable attempts to contact the above designated parties have been unsuccessful, for:
1) The administration of any treatment deemed necessary; and/or
2) The transfer of the child above to the requested hospital of another hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinion of a licensed physician deems the necessity for the surgery. I have reviewed this consent form and agree to its conditions on behalf of my child.
Parent or Guardian Signature *
Date *
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