LONG ISLAND PARK LACROSSE

REGISTRATION FORM

Player name: ______

Names of Parent/Guardian: ______

______

Email address: ______

______

School child attends; ______

Graduation Year: ______Birth Date ______

US Lacrosse Number: ______Expiration Date ______

Home address: ______

______

Contact Phone Numbers For one call system for information regarding games and programs: ______, ______

Player position: ______

Emergency Contact Numbers: 1st ______

2nd ______

Relevant medical problems: ______

I would like to volunteer as a team parent, please contact me: YES or NO

(Team parents will help with logistics such as organizing tailgates for tournaments, helping coordinate paperwork, and will work with directors as a team liaison)

Player Name: ______

Code of Conduct:

Teams’, players’, parents’ and coaches’ must conduct at all times good sportsmanship to become a participant in Long Island Park Lacrosse. This includes attendance and promptness during games as well as during practices. Players’ and parents’ are expected to respect their coaches, referees, and teammates, and abide by the rules and regulations of any facility, park or school that we have occupied as Long Island Park Lacrosse. Any player or coach whose conduct at any point in the season is deficient in this regard may be benched for part of a game or the entire game , or if a serious offense, suspended or removed from the team and Long Island Park Lacrosse. If a parent whose conduct at any point in the season is deficient in this regard will be asked to leave the facility, park or school. The primary objectives of Long Island Park Lacrosse are for all participants to have fun and learn the game of lacrosse. I have read this code of conduct and agree to it.

Parent/guardian print name: ______Date: ______

Parent/guardian signature: ______

Player’s signature: ______

Consent for Medical Treatment (Minor)

As the parent or legal guardian of the named player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb or well being of my dependent.

Parent/guardian print name: ______Date: ______

Parent/guardian signature: ______

Statement of Indemnification:

I, the parent/guardian of the player, a minor agree that the player and I will abide by the rules of Long Island Park lacrosse, its affiliates and sponsors. Recognizing the possibility of physical injury associated with lacrosse, and in consideration for Long Island Park Lacrosse accepting the player for its lacrosse programs and activities. I hereby release, discharge and/or otherwise indemnify Long Island Park Lacrosse, its affiliates and sponsors , its employees, board members, officers, coaches, volunteers, independent contractors, and associated personnel, including the owners of facilities utilized for its programs and activities, against any claim by or on behalf of a player as a result of the players’ participation in the programs and activities and/or being transported to or from same, which transportation I hereby authorize.

Parent/guardian print name: ______Date:______

Parent/guardian signature: ______

Insurance Information:

All participants are required to be covered with insurance for accidental injury. In most instances, family health insurance is adequate. Please indicate your family, or individual health plan below.

Insurance Company______Policy Number ______

TEAM REVOLUTION BLUE