Program Registration Template

Method of Payment *

If you pay by check we will need payment within 5 days of submitting this form or your spot will not be saved.

Division I want to play in *

You may play up or down with permission from the Hoosier Lacrosse Director.

Players Info

Players First Name *

Players Last Name *

Jersey Size *

Current Grade *

Your Current grade. If you are registering in the summer enter the grade you are going into.

Birthday *

Month

Day

Year

Contact Info

Address *

City or Town *

State *

Zip Code *

Primary Phone *

Emergency Phone *

Primary Email *

Secondary Email *

Waiver and Medical

List any serious illness or injury and all current medications

US Lacrosse membership # and expiration or Insurance Company and Policy Number:

Terms and Conditions *

Hoosier Waiver and Release of All Claims and Assumption of Risk

Please read this form carefully and be aware that in signing up and participating in the identified programs/activities, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with said programs/activities (including transportation services/vehicle operation, when provided).
I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of participating in these programs/activities against Hoosier Lacrosse, including its officials, agents, volunteers and employees (hereinafter collectively referred as Hoosier Lacrosse).

I do hereby fully release and forever discharge Hoosier Lacrosse from any and all claims for injuries, damages, or loss that my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associated with these programs/activities.

I have read and fully understand the above important information, warning or risk, assumption of risk and waiver and release of all claims. If registering on-line or via fax, your on-line facsimile signature shall substitute for and have the same legal effect as an original form signature.

I have read and understand this Waiver and Refund Policy.

I have read the above waiver, terms and conditions and agree to them. Full Name of parent, guardian or participant if 18 or older. * Electronic Signature -

Today's Date *

Month

Day

Year

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