Athlete’s Name: _______________________________ Date: __________________________
US Lacrosse #: __________________________ Exp Dt: _________________
Date of Birth:
AGREEMENT WAIVER AND CONSENT
The undersigned, as Parent or Legal Guardian of the above named student athlete, with the knowledge that the "Blaze at the Beach", "Summer Dayz" and "Autumn Heat" lacrosse tournaments are owned, hosted and managed by Coastal Carolina LAX, LLC a licensed North Carolina LCC partnership,(referred also as CCL, C3 and the 'Cudas) is providing the use of the athletic fields for practice and tournament space for the athlete to participate and compete with other players and lacrosse clubs in the sport of lacrosse. As parent/guardian the undersigned agrees that my child’s participation is subject to the following:
· I hereby promise and represent that my son/daughter has had a recent physical examination by a licensed physician, that there has been no material change in his/her physical condition since that examination and that he/she is currently medically, and physically fit to play lacrosse.
· I assume all responsibility for my son’s/daughter’s transportation to and from tryouts, practices, and games. CCL is not responsible for any transportation or any liability or injury arising from transportation supplied by others.
· I acknowledge that lacrosse is a potentially dangerous sport and that there are significant risks of injury, including paralysis or death. I agree to assume all risks and hazards incidental to his/her playing the sport. On behalf of myself and my child I hereby release, absolve and agree to indemnify and hold harmless CCL, its Organizers, Directors, and Officers, partners, any Sponsors, Coaches, Officials, Supervisors, the Owner(s) of the fields or equipment used, other participants from any losses, claims, or liability including costs of defense arising out of his/her participation. I further acknowledge that I have read and understand the foregoing waiver and release and that I have voluntarily agreed to give up substantial rights by signing the same.
· If this form is signed by one parent, such parent represents either that he/she alone has sole legal custody and responsibility for the child, or that he/she has discussed the contents hereof with the other parent who has consented and agreed to the contents hereof, and consents to the execution thereof.
· I represent that the personal representations made herein are true, accurate, and complete to the best of my knowledge.
· I acknowledge that my son/daughter is required to be a member of US Lacrosse in order to participate in CCL, and further acknowledge that it is my obligation to keep such membership current for so long as he/she participates in CCL events, practices and sessions.
Signature of Student Athlete: _______________________________________________
Signature of Parent or Legal Guardian: _______________________________________
