Loading...

Trilogy Lacrosse 2020 Camp 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. If you are a non-U.S. resident, you will need to provide a record of vaccination/immunizations.

I Agree

 

COVID-19 Acknowledgement of Risk:

I, (insert full name), hereby request you (Trilogy Lacrosse, LLC, TRILOGY) accept this agreement (Agreement) for my participation in the TRILOGY Event listed on this form (Event). In consideration of TRILOGY’S acceptance of this Agreement, I hereby agree to release, hold harmless, and indemnify Trilogy Lacrosse, LLC, the Township of West Caldwell, 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 while participating in the Event, or in traveling to or from the Event. I acknowledge that my participation/attendance in the TRILOGY Event includes possible exposure to and illness from infectious diseases such as COVID-19 and I willingly assume full responsibility of this risk. I certify that I have not recently tested positive for, am not exhibiting any symptoms of, or have 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 me. I agree that I, and anyone accompanying me to the Event will comply with all policies and precautions required by TRILOGY to ensure the safety of myself and other participants. Furthermore, I understand that my refusal to comply with these precautions may result in TRILOGY requesting my removal from the Event. I acknowledge that I have read this Release, fully understand its content and have agreed to it of my own free will.

I Agree

 

Medication Policy:

I understand that if my child takes any prescribed medication that will either need to be 1) administered by authorized camp health personnel or 2) self-administered by participant, I will need to fill out this information in this waiver. I will bring medication in original packaging to check-in and turn over to designated camp health personnel to administer as I specify in this waiver. Please note that self-administration is not permitted in the state of Massachusetts.

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 Event
Select 2020 Summer Camp Child is Attending*
Select Participant's High School Graduation Year*

Enter Participant's US Lacrosse Member # *
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
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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 my child take any prescribed medication?*

#1: List Diagnosis/Medication Name/Dosage/Administration Instructions

#2: List Diagnosis/Medication Name/Dosage/Administration Instructions
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 pertinent information on any health issues including physical, psychiatric, or behavioral issues. *
COVID-19 Questionnaire
Has the participant or a household member experienced a fever of 100.4 degrees Fahrenheit in the past 14 days?*
No
Yes

If yes, please list your temperature(s) recorded and the date(s) that they were recorded on.
Has the participant or a household member experienced any symptoms of COVID-19 in the past 14 days? Symptoms include, but are not limited to: fever of 100.4 degrees Fahrenheit or more, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting, diarrhea.*
No
Yes

If yes, please list the symptoms shown and what dates they were shown on.
Has the participant or a household member knowingly been in close contact with person who has been diagnosed with, tested for, or quarantined as a result of COVID-19 in the past 14 days?*
No
Yes
Has the participant or a household member traveled domestically or internationally in the past 14 days?*
No
Yes

If yes, please list the location of travel, method of travel, and dates the travel occurred.
Does the participant have an underlying medical condition that would make you high-risk for severe illness from COVID-19? Conditions include, but are not limited to: Chronic Lung Disease, Asthma, Heart Conditions, Compromised Immune System, Obesity, Diabetes, High Blood Pressure, Chronic Kidney Disease.*
No
Yes
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*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Event
Select 2020 Summer Camp Child is Attending*
Select Participant's High School Graduation Year*

Enter Participant's US Lacrosse Member # *
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 - TRY IT FREE!