Excalibur Lacrosse Club
Excalibur Lacrosse Club -
Excalibur Lacrosse Club of Roanoke, Inc.
2009 Fall Registration F
Please check program(s) for which you are registering:
Boys Travel Program
___U11 __U13 __U15 __High School
Boys Developmental Program
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)
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: _________________________________________________________________________________
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
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,
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