“STEALTH” Summer Lacrosse Club
Coach: Wayne “MAC” Macuirzynski 352-316-1363
Participant’s Name (PLAYER) ______Parent/Guardian’s Name ______Street Address ______
City ______
State ______Zip Code ______
Home Ph. ______
Child’s Birth Date ______Age ______
Emergency Contact ______
Cell Phone ______
Family Physician ______
Physician Ph. ______
Special Information Regarding Medical History ______
Waiver & Release Form
I hereby give consent for my child/ward, ______, to participate in the STEALTH Summer Lacrosse Club. I know of, and acknowledge that my child/ward knows of, the risks involved in athletic participation, understand that serious injury, and even death is possible in such participation and choose to accept any and all responsibility for his/her safety and welfare while participating in athletics. I do hereby waive, release and hold harmless the STEALTH Lacrosse Club and coach Wayne Macuirzynski and Casey Adams of any and all responsibility and liability for any injury or claim resulting from such athletic participation and agree to take no legal action against the “STEALTH” Lacrosse Club or Coach Wayne Macuirzynski and Coach Casey Adams because of any accident or mishap involving the athletic participation of my child/ward. I authorize emergency medical treatment for my child/ward should the need arise from such treatment while my child/ward is under the supervision of the “STEALTH” Lacrosse Club or it’s coaches. I further herby authorize the use of disclosure of my child’s/ward’s individually identifiable health information should treatment for illness or injury become necessary.
This waiver, release and indemnification is in consideration of the “STEALTH” Summer Lacrosse Club allowing my child’s/ward’s participation in the lacrosse activities and in further consideration of the “STEALTH” Lacrosse Club not requiring self-funded liability insurance coverage as a condition precedent to my child’s/ward’s participation in the activity. I freely and voluntarily assume for my child/ward all risk of loss or injury arising from my child’s participation in the activity whether due to my child’s/ward’s negligence or the negligence of others. I acknowledge that, absent from this release and indemnification, the “STEALTH” Summer Lacrosse Club would not have offered my child/ward access to the activity because of unacceptable exposure to liability claims or the expense of providing a program that is risk free.
I hereby give my consent to the “STEALTH” Summer Lacrosse Club or the host organization of any recognized event to provide, through a medical staff of its choice, customary medical/athletic training attention, transportation and emergency medical services as warranted in the course of my child’s/ward’s participation in the lacrosse event or activity.
US Lacrosse membership # MANDATORY!______
I have read and understand this release, waiver, and indemnification and sign it freely and knowingly, intending that it shall be fully operative and effective in all respects and that it waives legal rights to which my child/ward might otherwise be entitled if my child/ward is hurt or suffers loss during his/hers participation in the activity.
As parent or legal guardian of this participant, I hereby verify by my signature below that I have read and fully understand the above conditions for permitting my child/ward to participate in any “STEALTH” Summer Lacrosse Club recognized event or activity and I accept each of the above conditions.
Name of Parent/Guardian (Printed)
______
Signature of Parent / Guardian & Date
______