Polk County Youth Lacrosse

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Fall 7v7 Registration

* US Lacrosse Number:

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

* Birthdate:

* Email:

Gender:

* Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

* EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

I, the parent/guardian of the registrant, a minor, agree that I will abide by the rules of Polk Youth Lacrosse , its affiliated organizations and sponsors. Recognizing the possibility of physical injury with sports and in consideration for Polk Youth Lacrosse accepting the registrant for its sports programs and activities, I hereby release, discharge and/or otherwise indemnify Polk Youth Lacrosse , its affiliated organizations and sponsors, their employees, and associated personnel, including the OWNERS OF THE FIELDS and facilities used for the programs, against any claim by or on behalf of the registrant as a result of registrant's I, the parent/guardian of the registrant, a minor, agree that I will abide by the rules of Polk Youth participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent. I accept responsibility for providing accurate uniform sizes for my child and agree to bear the cost of a replacement if the uniform provided does not fit. I also agree to volunteer for Polk Youth Lacrosse when asked. I understand that in signing this application, I affirm that the information given above is true and correct. Polk Youth Lacrosse may be taking photos, videos, and other images of our participants throughout the season. These images will be the property of Polk Youth Lacrosse and may be shared with the media and posted on the internet. Polk Youth Lacrosse is hereby granted permission to use the image of the participant without further notification. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images and/or video taken for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and websites.

I/we agree with the above *

CONCUSSION and HEAT RELATED ILLNESS WAIVER

I accept responsibility for reporting all injuries and illnesses to my parents, team doctor, athletic trainer, or coaches associated with my sport - including any signs and symptoms of CONCUSSION. I have read and understand the information contained in the handout on concussion and heat related illness. I will inform the supervising coach, athletic trainer or team physician immediately if I experience any of these symptoms or witness a teammate with these symptoms. Furthermore, I have been advised of the dangers of participation for myself and that of my child/ward.

I/we agree with the above *

* indicates required fields

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Fall 7v7 Registration