Lacrosse Camp Release Form

Name: __________________________________________ Birthdate: ___/___/___ Age: _____

 

Address: ___________________________________ City: _______________ Zip: __________

 

Parent/Guardian Name: _________________________________________________________

 

Home Phone: ________________ Work Phone: ________________ Cell: _________________

 

Emergency Contact: ___________________________________________________________

 

Relationship: ____________________ Phone: ________________ Email: ________________

 

Existing Medical Coverage: __________________________ Plan #: _____________________

 

Medical Conditions: ____________________________________________________________

 

Known Allergies: ______________________________________________________________

 

Current Medications: ___________________________________________________________

 

I hereby voluntarily permit my child to participate in the Little Turtles Lacrosse Camp held June 12-14, 2018. I understand and fully accept there are risks involved in sports and that accidents and injuries are common. I hereby agree to accept any and all risks of injury, and verify this statement by placing my initials here. _________

 

As consideration for being permitted by the Wyandotte Nation to participate in these activities, I hereby release and hold harmless The Wyandotte Nation (staff, volunteers, coaches, and officials) from all liability, and from all actions or claims that my child now or hereafter may have due to injury, or to any person or property, resulting from an accident, negligence, or other acts in connection with my child’s participation. I further agree to indemnify and to hold The Wyandotte Nation (staff, volunteers, coaches, and officials) free and harmless from any loss, liability, damage, cost or expense which may incur as a result of any injury and/or property damage that my child may cause or sustain while participating in this activity. In case of a medical emergency, I hereby give permission to The Wyandotte Nation (staff, volunteers, coaches, and officials) to order treatment for my child, including any necessary medical treatment and x-rays. I also hereby give permission to The Wyandotte Nation (staff, volunteers, coaches, and officials) to disclose the information contained on this form to medical personnel. I understand that an attempt will be made to reach me by phone if transporting by ambulance becomes necessary. I agree to pay all medical, hospital, or other expenses which my child may incur as a result of necessary treatments. The Wyandotte Nation does not provide any medical or other insurance protection or benefits for participating in this activity.

 

I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ME AND THE WYANDOTTE NATION, AND SIGN IT OF MY OWN FREE WILL.

 

_____________________________________________________________ Date __________

 

Parent or Guardian Signature

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