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WAIVER, RELEASE OF LIABILITY, MEDICAL AUTHORIZATION & CONSENT TO TREAT

In consideration of each player’s participation in the sponsored activities of the Jackson Hole Lacrosse Club (“JHLC”), the below described player and parent/guardian acknowledge and agree to the following:

WAIVER & RELEASE OF LIABILITY. The below described player and parent/guardian are fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis, and even death, as well as other damages and losses, associated with the below described player’s participation in lacrosse. The below described player voluntarily agrees to participate in the JHLC program. The below described player and his/her parent/guardian and their heirs and representatives, hereby waive, release, and forever hold harmless JHLC and the sponsors of any JHLC sanctioned event, along with the past, present, and future coaches, volunteers, employees, agents, officers and directors of the foregoing organizations, from any and all liability for damages and claims for damages for personal injury, including accidental death, as well as from claims for property damage, and from any other liability, rights, claims, demands, damages, costs, expenses, actions, causes of action, suits of liability and controversies, known or unknown, foreseen or unforeseen, arising out of or in any way related to JHLC programs and/or equipment provided. Furthermore, this waiver and release of liability applies in the event of personal injury, including accidental death, as well as from claims for property damage, and from any other liability that occurs as a result of player voluntarily leaving the location of any JHLC event, including practices or games.

READINESS TO COMPETE. The below described player will only participate in those Jackson Hole Lacrosse Club events and competitions for which such player believes he/she is physically and psychologically prepared to compete.

CODE OF CONDUCT. The below described player has read and agrees to all terms in the Jackson Hole Lacrosse Club Code of Conduct, especially with regard to his/her responsibilities as a player.

MEDICAL AUTHORIZATION AND CONSENT TO TREAT. I (adult player/ parent/ guardian), hereby grant my authorization and consent for the Jackson Hole Lacrosse Club and its coaches, volunteers, employees, agents, officers and directors to obtain medical care and/or administer general first aid treatment for any injuries or illnesses experienced by the foregoing described player in the course of participation in, or attendance at, JHLC events, including practices and games. If the injury or illness is life-threatening or in need of immediate or emergency treatment, I authorize JHLC and its coaches, volunteers, employees, agents, officers and directors to summon any and all professional personnel (including emergency personnel) to attend, transport, and treat the foregoing described player and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, clinic or other medical professional or institution duly licensed to practice in the state in which treatment is to occur. I agree to assume financial responsibility for all expenses of such care.

I hereby certify that, as the parent/guardian of the foregoing described player, I have legal responsibility for and authority to sign this WAIVER OF LIABILITY, MEDICAL AUTHORIZATION & CONSENT TO TREAT on behalf of the foregoing described player. I further certify that I have read this WAIVER OF LIABILITY, MEDICAL AUTHORIZATION & CONSENT TO TREAT in full, understand the same and have signed it voluntarily and without any duress or coercion.

PHOTO AUTHORIZATION. Photos and video taken of below described participant while participating at the Jackson Hole Lacrosse Club games, practice, or events may be used in and for any JHLC publications, advertisements, or social media.

EMERGENCY MEDICAL PLAN.  In the event of an injury that requires medical attention outside the scope of the coach (i.e. bandaid, ice, etc.), the parents will be notified, and if necessary the player will be transported to the hospital or urgent care facility by a coach, team manager, or JHLC staff member.

In the event of an injury/emergency that which is life-threatening or requires the player to be stabilized, notably any potential neck injury, the coach or team manager will call 911 to arrange for emergency medical services.

In any medical emergency, the coach or team manager will contact the parents of the affected player at the primary phone number listed and all emergency contacts listed on the Medical Waiver and explain the injury/emergency.

Today's Date: August 26, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
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, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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 Information

Year Covered (Spring and Fall Seasons):
Participant's Team Name*
Participant's Team*
Boys 8U
Boys 10U
Boys 12U
Boys 14U
Girls 8U
Girls 10U
Girls 12U
Girls 15U
Girls HS
Participant's Grade*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Player Position*

Player Jersey #

Primary Physician's Name/Phone:

Hospital of Choice:

INSURANCE INFORMATION:

If said participant is covered by any insurance company, please complete the following:


Insurance Company:

Policy Number:

Primary Insured:

**Excess accident insurance, subject to deductibles, exclusions and limitations, is provided to all US Lacrosse registered team participants. For further details, contact your team manager.

MEDICAL HISTORY (completion of medical history information below is optional): 

If you check any of the following questions, please describe the problem and its implications for proper first aid treatment below.
Prior Concussion(s)
Head Injury
Fainting Spells
Convusions/Epilepsy
Hernia
Asthma
High Blood Pressure
Kidney Problems
Heart Murmur
Allergies ​(noted below)
Diabetes
Neck/Back Injury
Other

Have you had (or do you currently have) any of the following:

Has the participant had a recent tetanus booster?*
No
Yes

When?
Is the participant currently taking any medications?*
No
Yes

If yes, list:
Has a doctor restricted the participant's activities?*
No
Yes

If yes, please explain.
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.


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