HUNTLEY YOUTH LACROSSE – SPRING, 2016

AMATEUR ATHLETIC WAIVER AND RELEASE OF LIABILITY

READ BEFORE SIGNING

IN CONSIDERATION OF ______being allowed to participate

Name of Participant

in any way in a Northwest Chicago Youth Lacrosse Federation League (NWCYLF), Illinois Boys Lacrosse Association (IBLA) and Huntley Raiders Lacrosse Club (HRLC)athletic sports program, related events and activities, the undersigned acknowledges, appreciates, and agrees that:

  1. The risk of injuries from the activities involved in these programs is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
  1. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
  1. I willinglyagree to comply with the program’s stated and customary terms and conditions for participation. If, however, I observe any unusual significant concern in my readiness for participation and/or in the program itself, I will remove myself from the participation and bring such attention of the nearest official immediately; and,
  1. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS, School District 158, NWCYLF, IBLA, Huntley Lacrosse; it’s directors, officers, officials, agents, employees, volunteers, other participants, sponsoring agencies (i.e. U.S. Lacrosse, Illinois Lacrosse Association), sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event(s) (“RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to persons or property incident to my involvement or participation in these programs, WHETHER ARISING FROM NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
  1. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

______

Participant Signature Participant Name (Print)

______

Date Signed

UNDERSTANDING OF RISK

I understand the seriousness of the risks involved in participating in this program, my personal responsibilities for adhering to rules and regulation, and accept them as a participant.

______

Participant Signature Participant Name (Print)

______

Date Signed

FOR PARTICIPANTS OF MINOR AGE (UNDER 18 AT THE TIME OF REGISTRATION)

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and for myself, my heirs, assigns and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities or injuries incident to my minor child’s involvement or participation in these programs as provide above, EVEN IF ARISING FROM THEIR NEGLIGENCE.

______

Parent/Guardian Signature Parent/Guardian Name (Print)

______

Date Signed

EMERGENCY INFORMATION

Player’s Name (Print): ______

Player’s Address: ______

Player’s Date of Birth: ______

Person to Contact in Case of Emergency (Print): ______

Relationship to Player: ______Phone: ______Cell: ______

MEDICAL DISCLOSURE

Physician’s Name (Print): ______Phone: ______

Name of Insurance Company: ______Phone: ______

Name of Policyholder (Print): ______Group #: ______

Circle the appropriate choice(yes/no) below:

NO, I am not aware of any health problem of medical condition that will prohibit my child/ward from participating in this lacrosse program.

YES, Iam aware of the following health problem or medical condition that may affect my child/ward from participating in this lacrosse program.

Please describe condition/list allergies to medications: ______

______

If neither the parents nor the physician can be contacted in case of serious injury or illness, I authorize Northwest Chicago Youth Lacrosse Federation League (NWCYLF), Illinois Boys Lacrosse Association (IBLA) and/or Huntley Lacrosse to take such emergency action as may be deemed necessary including transportation to a hospital or medical center. As a parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of my child in the event of a medical emergency, which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort.

Signature of Parent or Guardian: ______Date: ______

Emergency Phone: ______

Page | 1