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Girls

North Country Lax Academy

Camper Check-in Form

I, (parent/guardian) hereby request you (Bitter Lacrosse, LLC, BITTER LACROSSE) accept this agreement (Agreement) for my childs enrollment in the BITTER LACROSSE Event(s) listed on this form (Events). In consideration of BITTER LACROSSE acceptance of this Agreement, I hereby agree to release, hold harmless, and indemnify Bitter 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 BITTER LACROSSE 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 the Events, and I agree that my child will wear their helmet at all times during the Events.

The novel coronavirus, COVID-19, is contagious and is believed to spread mainly from person-to-person contact. Bitter Lacrosse LLC has put in place preventative measures to reduce the spread of COVID-19; however, Bitter Lacrosse LLC cannot guarantee that your child will not become infected with COVID-19. Further, attending the Event(s) could increase your child's risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child may be exposed to or infected by COVID-19 by attending the Event(s) and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child in connection with my attendance at the Event(s) (“Claims”). On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless Bitter Lacrosse LLC, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Bitter Lacrosse LLC, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after attending the Event(s). 

I Agree

I understand that if my child takes any prescribed medication that will either need to be 1) administered by authorized Bitter Lacrosse 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 Bitter Lacrosse health personnel to administer as I specify in this waiver.

I Agree

I certify that I comply with the current State of Vermont traveler guidelines and the health and safety requirements for traveling to, from, and within the State of Vermont. I further certify that I understand all travelers should stay home if ill (with any symptoms); maintain physical distance of at least 6’ from anyone outside their household; wear a cloth mask when in public spaces; and wash or sanitize hands often.

I Agree

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
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 event information and updates
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Dietary Restrictions and Food Allergies

List all dietary restrictions/food allergies. Write "none" if no dietary restrictions/food allergies. *
Medications

List diagnosis and medication name, dosage and administration instructions. Write "none" if no medications. *
Additional Health Information

List any non-food allergies (i.e. bee stings, penicillin). Write "none" if no allergies. *

List any other medical information you would like us to be aware of (i.e. serious sports injuries, seizures). Write "none" if no other pertinent medical history. *
QUESTIONS/COMMENTS
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*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Choose Session *
Session I Girls: OVERNIGHT
Session I Girls: DAY
Session II Girls: OVERNIGHT
Session II Girls: DAY
Session III Girls: OVERNIGHT
Session III Girls: DAY

Position *
Graduation Year*
Shirt Size (adult)*

List all roommate requests. Write "none" if no roommate requests. *
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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