Atlanta Stampede Waiver (Release) of Liability and Assumption of Risk

Parent/Guardian Name(s):
Emergency Contact/Relation:
Emergency Contact Phone #:
Player’s Name:
Address, City, State, Zip:
Phone Number/Email Address:
Primary Insurance Carrier:
Group Plan or Policy #:
Any Medical Issues:

US Lacrosse Number ______Exp Date: ______

In consideration of being allowed to participate in anylacrossegames, practices, scrimmages, tournaments, related events and/orANYlacrosse related activities, I, theundersigned, acknowledge, appreciate and agree that:

  1. The risk of injury from the activities involved in playinglacrosse is significant,including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and I knowingly and freely assume all such risks, both known and unknown, and assume full responsibility for the undersigned playersparticipation;
  2. Because these activities may be hazardous in nature and/or include physical and/or strenuous activity, I verify that the undersigned player has been checked by a licensed physician within the past year and is physically able to participate in ALL sports related activities. I understand the inherent risk involved and I hereby do assume all risks included in the undersigned players participation in such activities. If at anytime during the lacrosse season(s)the undersigned players physical state changes and she is no longer able to participate, It will be my responsibility to notify all coaches, staff, volunteers and players immediately and ONLY UPONA DOCTORS CLEARANCE will the undersigned player be allowed to begin playing again.
  3. I, the undersigned, In the case of injury or medical emergency and in the event the undersigned players parent or guardian, cannot respond at the time of the emergency, give Atlanta Stampede coaches and or volunteers permission to seek, administer, or have administered whatever first aid or emergency medical care deemed necessary for players welfare. It is understood that any cost associated with such services received during the player’s participation in the sport of lacrosse will be the sole financial responsibility of the undersigned parent/guardians and NOT Atlanta Stampede, its coaches and/or volunteers.
  4. I, the undersigned, for myself and on behalf of my heirs,assigns, personal representatives and next of kin, herebyrelease, indemnify and hold Atlanta Stampede and their coaches, volunteers, officers, officials,agents and/or employees, other sport participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event or activity (“Releases”) harmless with respect to any and all injury, disability, death, or loss or damage to person or property, to the fullest extent permitted by law.

I HAVE READ THIS WAIVER (RELEASE) OF LIABILITY AND ASSUMPTION OF RISKAGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVENUPSUSTATNTIAL RIGHTSBY SIGNINGIT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Parent/Guardian Signature:Date:

Player/Participant Signature:Date: