Mills Park Girls Lacrosse Club Program Waiver

August 2017 - May 2018

Players Name: ________________________________________________________________

Age: _____________ DOB: _____________

Street Address: _______________________________________________________________

City: _________________________ Zip Code: _____________

US Lacrosse # (if you have one): ________________________________ Exp. Date: _______

Parent/Guardian Name(s): ______________________________________________________

Home Phone #(s): ______________________________________________________________

Cell Phone #(s): ________________________________________________________________

Emergency Phone#(s): __________________________________________________________

Insurance Provider: _______________________________ Policy Number: _______________

For purposes of clarity, the Mills Park Girls Lacrosse Club will be referenced below
as the Program.

I hereby waive and release Alyson Adams and Brian Milberg and all coaches from any
and all liability for injuries incurred while taking part in the Programs practices,
games and participation in third-party events, as well as all liability for injuries
incurred while traveling to or from said practices, games or third-party events.

In the event of any injury or illness, all reasonable efforts will be made to contact the
Parent/Guardian to obtain authorization for medical treatment. Where
Parent/Guardian cannot be contacted or in case of emergency, the coaches will obtain
the necessary medical treatment for the health of my child.

I am fully aware of and appreciate the risks associated with participation in a

lacrosse activity or event, including the risk of injury or death, as well as other types
of damages and loss. I further agree on the behalf of my child that all coaches, host
organizations and/or entities shall not be liable for any injury, loss of life or other
loss or damage occurring as a result of the participation in the Program.

My signature below is my acknowledgement that I have read and understood every

provision of this Waiver and Release of Liability, and that I agree to abide by it.

Parent/Guardian Signature:

__________________________________________________________ Date: ______________

Parent/Guardian Name (Please print):

______________________________________________________________________________