November 17, 2019


I, being the legal guardian of the individual named on this form, certify that he is in good physical condition and is capable of participating in this CAPITAL LACROSSE, LLC program. If medical attention beyond first-aid treatment is required, I understand that every attempt will be made to contact me at the emergency numbers provided. If contact with me is not possible, I give permission for medical attention to be administered. Furthermore, I hereby release, exonerate and discharge CAPITAL LACROSSE, LLC and its officers, staff, administrators, volunteers, sponsors and representatives and assigns for and against any and all injuries, damages, claims, actions, cause of actions, suits, judgments and demands incurred while participating in, or traveling to and from, this program. By signing below, I acknowledge that I have read and understand this form and further understand the terms herein are contractual and not a mere recital.

Date: November 16, 2019

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

First Name*

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

Grade: *

Team Name: *

Coach's Name: *
First Participant's Signature*
Parent or Guardian's Email Address

A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*

Insurance Carrier*

Insurance Policy Number*
Travel & Hotel Information
Does your participation in the Colonial Challenge necessitate an overnight stay in the Williamsburg area?*
How many nights will you be staying in the Williamsburg area?*

Hotel or resort where you will be staying *
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*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Grade: *

Team Name: *

Coach's Name: *
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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