( circle one )
Player_____________________________    Position:  Attacker    Goalie

PLAYER Email:___________________________________________
( Please print Email clearly )
TEAM / School___________________________________________

Emergency Contact (other than Parent) ______________________________

I understand that: 1) My child is in good physical condition and has had a physical examination in the last 365 days; 2) I am hereby waiving and releasing Great Western Lacrosse, the Great Western Lacrosse indoor lacrosse League, its Director and all staff, the San Diego Indoor Soccer Center, and any sponsors, of any and all liability for injuries incurred by my child while playing in the league even if arising from negligence; 3) I understand that this League is run at a facility with artificial grass; 4) I am aware that this league is a "play at your own risk" league and that I must have primary medical insurance coverage that blankets my child, the participant; 5) I am aware that this is a "no hit" league, I have discussed this with the participant. I am also aware that any disregard of the rules will result in expulsion from the league without refund and that the Director, the Coaches and/or the Referee have the irreversible right and judgment to expel any player.  In the event that my child is injured and I am unable to give parental consent, I hereby authorize the Physician/Hospital Staff at any Hospital to provide care to include diagnostic procedures and medical treatment as necessary to my child, who is a minor.  By signing below, I am entering into a contract willfully and without coercion. I am aware that the fee of $120.00/$135.00 is non-refundable for any reason after 10 / 1 / 2008, not even for an injury.