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Medical Waiver

Medical Release Waiver Form

True Lacrosse, Inc.

655 W Grand Avenue, Suite 130

Elmhurst, IL 60126

630-359-5542

www.truelacrosse.com

 

 True Lacrosse, Inc.  - -EMERGENCY MEDICAL RELEASE & LIABILITY WAVIER

 

Player’s Name___________________________________________Birthdate____________________

Street Address__________________________________________City______________Zip_________

Email Address__________________________________________

Program Waiver applies to: ________________________________ Dates: ____________________

 

EMERGENCY INFORMATION

Father’s Name___________________________Phone__________________Cell________________

Mother’s Name__________________________Phone___________________Cell________________

In case of emergency when parent/guardian cannot be reached, please contact the following:

Name: __________________________________Phone: __________________Cell________________

Name: __________________________________Phone: _________________Cell_________________

 

MEDICAL/INSURANCE INFORMATION

Allergies: ___________________________________________________________________________

Other Medical Conditions: _____________________________________________________________

Physician: _____________________________________Phone: _______________________________

Medical/Hospital Insurance Company: _________________________Phone: __________________

Policy Holders Name: __________________________Policy#________________________________

 

I the undersigned (if applicant/participant is 18 years of age or older) or parent/guardian of the above listed minor applicant/participant acknowledge and fully understand that each applicant/participant will be engaging in activities that involve risk of serious injury, including permanent disability or death and severe social and economic losses which might result not only from their own actions, inactions and negligence but action, inaction or negligence of other, the rules of play or the conditions of the premises or of any equipment used and further, that there may be other unknown risks not reasonable, foreseeable at the time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not sue True Lacrosse Club , their affiliated organizations and sponsors, their coaches, managers, employees and associated personnel, officers, members of the Board of Directors, agents, including the owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as “releasees,” from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant’s participation in the Programs and/or being transported to or from Programs. I hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I, also agree to save and hold harmless and indemnify each and all parties herein referred to above as release from all liability, loss, cost, claim or damage whatsoever, including death or damage to property which may be imposed upon said releasee because of any defect in or lack or such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasee. I have read the above waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily.

 

PHOTO WAIVER

Participants or their parent (if participant is under the age of 18) permit the taking of photos, video and audio tapes during True Lacrosse programs and events for the publication in True Lacrosse brochures, website, advertising and use as True Lacrosse deems necessary. 

 

 

Parent/Guardian Signature____________________________________________Date___________

Printed Name____________________________________________________

 

NOTE: THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT MUST BE COMPLETED BEFORE A PLAYER BEGINS PARTICIPATION. TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDED HEREIN.

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