Player_____________________________________________    Indoor Position:    Field Player       Goalie        
                                                                                                                                             ( circle one )Address_________________________________________________________________________

City__________________________________________    State_____ Zip___________ Grade_____

Phone__________________________ Birth Date_______________ Age_________ (IMPORTANT)

PLAYER Email:_____________________________________________________________________
( Please print Email clearly )
TEAM / School______________________________________________________________________

Emergency Contact (other than Parent) ________________________________________________________
Emergency Contact’s Phone___________________________________________________________

US Lacrosse Number___________________________________ Expiration Date______________    
I am not a member of US Lacrosse_______

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 Peninsula YMCA, 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 $150.00 is non-refundable for any reason after 9 / 15 / 2012, not even for an injury.