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Excalibur Lacrosse Club -

Excalibur Lacrosse Club of Roanoke, Inc.

2009 Fall Registration Form

Please check program(s) for which you are registering:

Boys Travel Program

___U11           __U13                        __U15             __High School

Boys Developmental Program

__U9/U11        __U13/U15

Player Information:

Player’s Name                                                                                                                        Birth Date & Year

U.S. Lacrosse membership number                                                                        Grade in School/Name of School

________________________________________________________________________________________________

Parents’ Names and address  

Home Phone Number                             Work Phone Number                              Parents’ Cell Phone Number(s)

E-mail address                                                                                                                         Alternate e-mail address

Emergency contact person if parent cannot be reached (include phone number)

Health Information:

Please list any health problems that might be important to a physician evaluating the player in case of an emergency:

Please list any allergies and current health conditions or medications:  _______________________________________

________________________________________________________________________________________________

Insurance Company:  _________________________________________Policy # ______________________________

Name of insured:  _________________________________________________________________________________

Emergency Authorization:

In the event I cannot be reached in an emergency, I hereby give permission to physicians selected by the coaches and staff to hospitalize and secure proper treatment for the player named above.

Signature of parent or guardian

Agreement:

I, the undersigned parent or guardian of the above named player, hereby apply to Excalibur Roanoke Lacrosse Club of Roanoke, Inc. for permission for the player to participate in the Fall Program.  As a condition, we agree to the following:

1.  Pay announced fee upon registration or, for travel program, after completion of tryouts.

2.  Should the player borrow any equipment from a fellow player, Excalibur Lacrosse Club of Roanoke, Inc. shall not be responsible for its safety or condition.

3.  The player is mentally and physically fit to play lacrosse.

4.  I acknowledge that lacrosse is a potentially dangerous sport, and assume all risks and hazards incidental in

playing the sport.  I, on behalf of myself, my spouse, the player and out heirs and personal representatives, hereby release, indemnify, and hold harmless Excalibur Lacrosse Club of Roanoke, Inc., its directors, officers, employees, agents, coaches and staff from any claim of liability arising out of participation on this team. I have legal custody and responsibility for the player.

Signature of parent or guardian                                                                                               Date

Please send checks (payable to Excalibur Lacrosse Club of Roanoke, Inc.) and completed and signed form and to Excalibur Lacrosse Club at P.O. Drawer 1200, Roanoke, VA 24006.

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