Loading...

Trilogy Lacrosse 2019 Intensive Club Experience Medical Form & Waiver

Medical Release:

I, (parent/guardian) hereby request you (Trilogy Lacrosse, LLC, TRILOGY) accept this agreement (Agreement) for my child's enrollment in the TRILOGY event(s) listed on this form (Events). In consideration of TRILOGY acceptance of this Agreement, I hereby agree to release, hold harmless, and indemnify Trilogy Lacrosse, LLC, and all of their respective owners, agents, employees, sponsors, representatives and assigns, from and for any and all claims resulting from any injuries or death sustained by my child while participating in the Events, or in traveling to or from the Events. I acknowledge that lacrosse is a contact sport, and understand that, although rare, there is a risk of serious injury or death associated in playing the sport. I hereby give permission to the coaches, training staff, and other medical professionals to provide medical care as deemed necessary to my child in case of any injury or illness. Photos and video taken of my child while participating at the Events may be used in and for any TRILOGY publications and advertisements. I warrant and represent that I have the authority to sign this Agreement on behalf of my minor child. Signing this Agreement, and registration of my child in the Events, shall act as my consent for any such advertising usage. I acknowledge and agree that I am responsible for outfitting my child with the appropriate equipment (stick, gloves, elbow pads, shoulder pads, mouth guard and helmet for boys; stick, goggles and mouth guard for girls) for the Events, and I agree that my child will wear their helmet and appropriate equipment whenever on the Field during the Events. 

I Agree

Please select who will be participating...
Minor
Continue
First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's HS Graduation Year
Select your HS Graduation Year*
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information from Trilogy Lacrosse.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Primary Care Physician

Primary Care Physician Full Name *

Primary Care Physician Phone *
Dietary Restrictions and Food Allergies
Does Participant Have Any Dietary Restrictions or Food Allergies?*

List All Dietary Restrictions. Write "None" if no Dietary Restrictions. *
Asthma
Does participant have asthma that requires use of an inhaler?*
Additional Health Information
Does Participant Have Any Non-Food Allergies?*

If Yes, List Non-Food Allergies i.e bee stings, penicillin. Enter "None" if no. *

Please list any other medical information or medication you would like us to be aware of? i.e. Serious Sports Injuries, Diabetes, Seizures. Enter "None" if no. *
Medication
Does Your Child Take any Prescribed Medication?*

#1: List Diagnosis/Medication Name/Dosage/Administration Instructions. *If you are attending Future Aces East, you will need to sign a Medication Administration Form for each medication that you are bringing that is signed by a physician, per MD State Law. This Form will be emailed to you prior to this Event. (write N/A if no medication is taken). *

#2: List Diagnosis/Medication Name/Dosage/Administration Instructions (write N/A if none) *
Medication Policy
I understand that if my child takes any medication: 1) medication is self-administered by the child, 2) the child's physician or authorized prescriber must provide written authorization for the child's self-administration of the medication, 3) the child self-administers the medication while under camp staff supervision. I will bring medication in original packaging to check-in and turn over to designated camp health personnel (emergency medication is not required to be turned in). If the child has emergency medication, I authorize the child to self-carry emergency medication. I request and authorize self-administration of the below listed medication for the child named above under the supervision of a designated staff member as prescribed by the below authorized prescriber. I certify that I have legal authority to consent to medical treatment for the child named above, including the administration of medication at the facility. I understand that at the end of the authorized period, an adult must pick up the medication; otherwise it will be discarded. I authorize camp personnel to communicate with the authorized prescriber, as allowed by HIPAA. *
I Agree
U.S. Resident
If participant resides outside of the United States, a record of vaccination/immunization must be submitted.
I reside in the United States
I reside outside of the United States
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's HS Graduation Year
Select your HS Graduation Year*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver