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Health & Release of Liability Waiver

I agree, warrant and covenant as follows:

Release for Medical Treatment: “I, the parent or guardian of the named LACROSSOVER, LLC participant(s), give permission for my child to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me, or the Emergency contact recorded, before taking action. I hereby waive and release LACROSSOVER, LLC staff and students from any liability for any injury or illness sustained while participating in a camp/clinic/training session or traveling to and from the activities. I UNDERSTAND THERE IS A RISK OF INJURY OR ILLNESS TO MY CHILD AS A RESULT OF CAMP/CLINIC/TRAINING ACTIVITIES, AND I KNOWINGLY AND VOLUNTARILY ASSUME ALL RISK OF SUCH INJURY OR ILLNESS. I will be financially responsible for any medical attention needed during camp or resulting from any injury received at camp/clinic/training session or resulting therefrom. My medical insurance shall be the insurance coverage for any medical treatment.”

Physical Certification: “I hereby certify that the named camp/clinic/training participant is physically able to participate in LACROSSOVER, LLC programs and that I know of no restrictions, physical impairments, or any other facts, which in any manner limit or should limit her participation in such a program.”

US Lacrosse Membership: "I hereby certify that the named LACROSSOVER, LLC participant carries a current US Lacrosse membership."

Publicity Release: "I understand that LACROSSOVER, LLC retains the right to use photographs and videos of participants taken during camps or clinics for publicity and advertising purposes."

By accepting this waiver, you are signing LACROSSOVER, LLC Clinic Health and Release Authorization, and you are accepting the Policies and Procedures.

First Player's Name

First Name*

Last Name*

Phone*
First Player's Date of Birth*
First Player's Signature*
Second Player's Name

First Name*

Last Name*
Second Player's Date of Birth*
Third Player's Name

First Name*

Last Name*
Third Player's Date of Birth*
Fourth Player's Name

First Name*

Last Name*
Fourth Player's Date of Birth*
Fifth Player's Name

First Name*

Last Name*
Fifth Player's Date of Birth*
Sixth Player's Name

First Name*

Last Name*
Sixth Player's Date of Birth*
Seventh Player's Name

First Name*

Last Name*
Seventh Player's Date of Birth*
Eighth Player's Name

First Name*

Last Name*
Eighth Player's Date of Birth*
Ninth Player's Name

First Name*

Last Name*
Ninth Player's Date of Birth*
Tenth Player's Name

First Name*

Last Name*
Tenth Player's Date of Birth*
Player's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
US Lacrosse Number
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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