REGISTRATION FORM PACKET 2015 BUTLER BOYS SCHOLASTIC LACROSSE ASSOCIATION PLEASE SIGN ALL FORMS & RETURN ENTIRE PACKET
BUTLER BOYS SCHOLASTIC LACROSSE ASSOCIATION RELEASE FORM In consideration of the acceptance of the below named minor child as a participant in the Butler Boys Scholastic Lacrosse Association lacrosse program, I/we, the undersigned, hereby authorize such participation, with full recognition and acknowledgment of the hazards and risks attendant to said child s participation in said activity and do hereby accept the risks therein attendant. I/we further hereby release, acquit, absolve, indemnify, forever discharge, and hold harmless the Butler Boys Scholastic Lacrosse Association, its agents, servants, employees and assigns, including but not limited to the organizers, officers, sponsors, volunteers, and employees of said organization, and their heirs and assigns. I further authorize and permit any officer, agent, servant, or employee of the Butler Boys Scholastic Lacrosse Association to render assistance and /or emergency (first-aid) medical treatment to said minor child if, in the judgment of said individual, such treatment is required, and do further authorize and permit any officer, agent, servant, or employee of the Butler Boys Scholastic Lacrosse Association to execute a consent, authorization, or permission, or to otherwise procure or obtain medical treatment and care for said minor child if circumstances warrant, and do hereby release, acquit, absolve, indemnify, forever discharge, and hold harmless the Butler Boys Scholastic Lacrosse Association, its officers, agents, servants, or employees, for any charges, injuries, damages, or other liabilities, whethe r foreseeable or unforeseeable, accruing from the rendering or procurement of medical treatment, or any act or omission of any act, related or attendant to the said medical care and /or need therefore. I/we further agree and covenant with the Butler Boys Scholastic Lacrosse Association, that I/we will never sue or bring legal proceeding against said Butler Boys Scholastic Lacrosse Association, it s officers, agents, servants, or employees, for or on account of any injury or damage that I/we may sustain by virtue of or arising out of said minor child s participation in said lacrosse program, including any injury or damage sustained during transport of said minor child to or from any program events or practices, or for any claim or demand I/we may have agai nst said Butler Boys Scholastic Lacrosse Association, its agents, servants, officers, or employees, and these presents may be pleaded as a complete defense to any action or claim so brought, reserving unto me/us the right to proceed against any other parties involved in said action or claims. This is a joint and several obligations of the parties hereto. In witness whereof, I/we have set my/our hand and seal hereunto this document NAME OF CHILD (please print) Signature of Parent(s)/Legal Guardian(s) Date
BUTLER LACROSSE PROOF OF INSURANCE PLAYER NAME (print): BIRTH DATE: / / ADDRESS: HOME PHONE: AGE: GRADE: NAME OF PARENT/ LEGAL GUARDIAN CARRYING INSURANCE: EMPLOYER: WORK PHONE # INSURANCE CARRIER: POLICY NUMBER GROUP NUMBER: EFFECTIVE DATE / / Insurance requirements: The player and his/her parent/guardian named above understands and agrees that primary medical insurance coverage is required and must be provided on a continuous and uninterrupted basis in conjunction with player participation in any Lacrosse activity inc luding and without limitation to warm-up, practices, scrimmages, games, pre and post season tournaments, playoffs and all other games. Change of Insurance status: In the event that the player s primary medical insurance coverage terminates during the time of registration, the player and parent guardian agree to immediately withdraw from participation in all Lacrosse activity and notify the Butler Lacrosse Association of the change in insurance status. Failure to provide insurance coverage: No Butler Boys Scholastic Lacrosse Association member, officer, coach, employee or agent may permit any player to participate in any Lacrosse activity until BBSLA has received proof of insurance in accordance with its rules and regulations. I acknowledge, understand and agree to these terms and conditions. Signature of Parent or Legal Guardian Name (Print) of Parent or Legal Guardian
Butler Boys Scholastic Lacrosse Association Acknowledgment of Receipt of Releases and Codes of Conduct and Agreement to Comply with Said Documents I am aware that Butler Area School District has a Code of Student Conduct that regulates participation in school activities. I agree that though Lacrosse is a club sport, the eligibility to participate is at a minimum dependent on meeting the Butler Area School District requirements. These requirements include exceeding the minimum grade and disciplinary standards. Additional Butler Boys Scholastic Lacrosse Association Code of Conduct standards have been adopted by the Association. Copies of each have been provided to you. Participation in Lacrosse will be dependent upon strictly adhering to all codes of conduct We, the undersigned, acknowledge the receipt of the listed documents and agree to comply with all tenets listed in said documents. Failure to do so may result in suspension or expulsion from the association and /or civil or criminal action as appropriate. The Board of Directors of the Butler Boys Scholastic Lacrosse Association will have sole authority in determining the remedy for infractions of the Codes of Conduct. In the event a parent or legal guardian is suspended or expelled from the association the athlete will receive the same remedy. We acknowledge receipt of the following documents: Parent/ Legal Guardian Initial Each Item: Risk of Injury w/information on Concussions/MRSA (orientation packet) Player, Parent & US Lax Code of Conduct (in orientation packet) Release of Liability (Return Completed with signatures) Insurance Agreement (Return Completed with signatures) Registration & Emergency Information (Return Completed) US Lacrosse Form (Return Completed with signatures) Received copy of BBSLA Revised By-laws Article VII (in orientation packet) Furthermore, we agree to read and abide by the rules set forth in these documents. Signed: Parent/Legal Guardian: Date:
BBSLA Player Contact & Emergency Information Please print neatly Player s Name: DOB Grade Mother s Name: Mother s Address: Mother s Home Ph#: Cell# Mother s Work #: Mother s Email Address: Father s Name: Father s Address: Father s Home Ph#: Cell# Father s Work Ph# Father s Email Address: Player s Cell Phone #: *Do we, BBSLA, have your permission to use the above listed phone numbers on team informational releases, i.e. team phone trees, concession schedules, etc.? YES or NO DATE OF LAST PHYSICAL: Was it done by the Butler Area School District? Yes or No Health Insurance Carrier Name: Policy # Known Medical Conditions: Known Allergies: Current Medication: Family Doctor Name and phone #: Hospital of Choice: SPECIALNOTES: Referred By: