US Lax Events, Inc.
175 E. Delaware St.
Chicago, IL60611
708 305 7014
US Lax Events,Inc.- -EMERGENCYMEDICAL RELEASE &LIABILITYWAIVER
Player’s Name_ Birthdate
StreetAddress City ZipEmailAddress
SecondaryEmailAddress
ProgramWaiver applies to: Dates:
EMERGENCYINFORMATION
Father’s Name Phone Cell
Mother’s Name Phone Cell
In case ofemergencywhen parent/guardiancannotbe reached, please contact thefollowing:
Name: Phone: CellName: Phone: _Cell
MEDICAL/INSURANCE INFORMATION
Allergies: Other MedicalConditions: Physician: Phone: Medical/HospitalInsuranceCompany: Phone:
Policy HoldersName: _Policy#
PLEASEREAD ANDSIGNTHEWAIVER ONTHEBACKSIDEOF THISFORM.
PLEASEREADCAREFULLY:
I theundersigned(ifapplicant/participantis18yearsofageorolder)orparent/guardianoftheabovelisted minor
applicant/participant,acknowledgeandfullyunderstandthat eachapplicant/participantwillbeengaginginactivities (the “Programs”) thatinvolveriskofseriousinjury,includingpermanentdisabilityordeathandseveresocialandeconomiclosseswhichmightresult notonlyfromtheirownactions,inactionsandnegligencebuttheactions,inactionsor negligenceofothers,therulesofplayorthe conditionsofthepremisesorofanyequipmentusedandfurther,thattheremaybeotherunknownrisksnotreasonablyforeseeableat thetime,andassumealltheforegoingriskandacceptpersonalresponsibilityforthedamagesfollowingsuchinjury,permanent disabilityordeath,and herebyrelease,discharge,andcovenanttoindemnifyandnotsue US Lax Events,Inc., itsaffiliated organizationsandsponsors,itscoaches, managers,employeesandassociatedpersonnel,officers, membersoftheBoardofDirectors, agents,includingtheownersandlesseesofpremisesusedtoconductthePrograms,allofwhicharehereinafterreferredtoas
“Releasees,”fromanyandallliabilitytoeachoftheundersigned,his/herheirsor nextofkinforanyandallclaimsbyoronbehalfof theapplicant/participantasa resultoftheapplicant/participant’sparticipationintheProgramsand/orbeingtransportedtoorfromthe Programs.I herebygive myconsentto haveanathletictrainer,coachand/ordoctorofmedicineordentistryorassociatedpersonnelto providetheapplicant/participantwithmedicalassistanceand/ortreatmentandagreetobefinanciallyresponsibleforthecostofsuch assistanceand/ortreatment.Ialsoagreeto saveandholdharmlessandindemnifyeachandallpartieshereinreferredtoaboveand releasesaidReleaseesfromall liability,loss,cost,claimordamagewhatsoever,includingdeathordamagetopropertywhichmaybe imposeduponsaidReleaseebecauseofanydefectinorlackofsuchcapacityto soactorcausedorallegedtobecausedinwholeorin partbythenegligenceoftheReleasee.Ihave read the abovewaivers/releasesand understand that (I) we havegiven up substantialrightsbysigningthisrelease and sign belowvoluntarily.
PHOTOWAIVER
Participantsortheirparent(ifparticipantisundertheageof18)permitthetakingofphotos,videoandaudiotapesduringUS Lax EventsprogramsandeventsforthepublicationinUS Lax Eventsbrochures,website,advertisinganduseasUS Lax Eventsdeems necessary.
Ihave read theabovewaivers/releasesand understand that(I)we havegiven up substantialrightsbysigningthisreleaseand sign belowvoluntarily.
Parent/GuardianSignature DatePrintedName
NOTE: THISAUTHORIZATIONFOR EMERGENCYMEDICALTREATMENT MUST BE COMPLETED BEFORE A PLAYER BEGINSPARTICIPATION. TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDEDHEREIN.