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Trilogy Lacrosse 2023 Future Aces East Medical Form & Waiver





Participant Waiver (Players)

I, {{FIRST_NAME}} {{LAST_NAME}}, hereby request you (Trilogy Lacrosse, LLC, TRILOGY) accept this agreement (Agreement) for my child’s participation in the TRILOGY Event listed on this form. In consideration of TRILOGY’S acceptance of this Agreement, I hereby agree to release, hold harmless, and indemnify Trilogy Lacrosse LLC, Towson University, and all of their respective owners, agents, employees, sponsors, representatives, vendors, venue affiliates and assigns, from and for any and all claims resulting from any injuries, illness or death sustained by my child or any member of my family while participating in the Event, or in traveling to or from the Event. 

I acknowledge that my child’s participation in the TRILOGY Event listed on this form includes possible exposure to and illness from infectious diseases such as COVID-19 and I willingly assume full responsibility of these risks. I certify that my child has not recently tested positive for, is not exhibiting any symptoms of, or has been in contact with someone confirmed to have COVID-19 nor has any member of my household or any individual that may attend the event with my family. I agree that my child, and anyone accompanying me to the Event will comply with all policies and precautions required by TRILOGY to ensure the safety of my child and other participants. Furthermore, I understand that my child’s refusal to comply with these precautions may result in TRILOGY requesting their removal from the Event. 

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, athletic training staff, and other medical professionals to provide medical care as deemed necessary to my child in case of any injury or illness. 

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 the Event, and I agree that my child will wear their helmet at all times on-field during the Event.

I certify that I have read and explained all of the provisions in this waiver to my child including the risk of possible exposure to infectious diseases such as COVID-19. My child understands and accepts these risks and responsibilities to adhere to the policies and procedure required by TRILOGY to mitigate these risks.

Photos and video taken of my child while participating at the Event 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 Event, shall act as my consent for any such advertising usage. 

I acknowledge that I have read this Release, fully understand its content and have signed below of my own free will.

I Agree






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

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
US Lacrosse Membership

All campers must be US Lacrosse members with active memberships to attend this event. To become a member or renew existing membership, visit uslacrosse.org/membership


US Lacrosse Member # *
Insurance

Insurance Carrier*

Insurance Policy Number*
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?*
Medication
Does Your Child Take any Prescribed Medication?*

#1: List Diagnosis/Medication Name/Dosage/Administration Instructions. *
Additional Health Information
Does Participant Have Any Non-Food Allergies?*
No
Yes

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

Please list any additional pertinent information or any health issues including physical, psychiatric, or behavioral issues. *
I authorize myself or the following individuals to pick up my son from camp:

Additional Authorized Pickup #1 Full Name & Phone Number

Additional Authorized Pickup #2 Full Name & Phone Number

Additional Authorized Pickup #3 Full Name & 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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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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