2012 Player Registration & Release

All players will need to complete this form by May 25, 2012.

Name of Minor/Participant:

First Name Last Name

Date of Birth

Player's Email (optional)

Parent's Email

Home Phone - -

Street

City State Zip

Team Information:
Note: Ages follow US Lacrosse Rules (i.e. for 2011: U9=2002 or later birth year; U11 = 2000; U13 = 1998; U15 = 1996)

Level / Team / Coach

Position

Emergency Information

Emergency Contact Name

Relationship to Participant

Emergency Contact's Phone - -

Health Insurer Policy Number

Participant's US Lacrosse Number

US Lacrosse Expiration Date

» Release and Waiver of Liability, Assumption of Risk, Indemnity and Parental Consent Agreement

I have READ and ACCEPT the Release and Waiver of Liability, Assumption of Risk, Indemnity and Parental Consent Agreement. This shall serve as my digital signature and is my binding mark.

Name of Person Completing Event Consent/Waiver Form

Relationship to Participant

I have read and agree to abide by the Liberty Lacrosse Shootout Code of Conduct

Subscribe me to the Liberty Lacrosse Shootout Mailing List