Fastbreak Lax, Inc.

Office:  4401 Cottington Road    Baltimore, Maryland 21236

Office:  410-931-2331    Fax:  410-931-2886    E-mail:  fastbreaklax@comcast.net        Web Site:  www.fastbreaklax.com

PLAYER PERMISSION FORM

GIRLS' HIGH SCHOOL INDOOR LACROSSE PROGRAM  2010-11

COMPLETE THIS FORM LEGIBLY AND HAVE ONE OF YOUR PARENTS SIGN THE LEAGUE AGREEMENT BELOW.  RETURN THIS FORM TO YOUR COACH.  THE COACH IN TURN WILL GIVE THIS FORM (or a photo copy of it) TO THE PROGRAM COMMISSIONER.

YOUR NAME (print) _____________________________

TEAM (be specific) _________________________________

HOME ADDRESS __________________________________________

                CITY/TOWN  ____________________  STATE ____    ZIP CODE __________

HOME TELEPHONE (include area code)  ______________________________

EMERGENCY CONTACT PERSON ______________________________________________

EMERGENCY PHONE NUMBER (include area code) _________________________________________

DATE OF BIRTH ________________________________________  AGE _____

LEAGUE AGREEMENT (to be read and completed by parent/legal guardian)

I agree NOT to hold Fastbreak Lax, Inc.,  its personnel and coaches, and Freestate Indoor Sports Arena responsible for any injury to my daughter/ward while playing in this program.  I further agree that my daughter/ward is in good physical health and is fit to participate in indoor lacrosse.  I understand that my daughter/ward must always wear a mouth guard and regulation eye protection while playing, and that this equipment is in good condition.  Fastbreak Lax, Inc. and Freestate Indoor Sports Arena do NOT carry health insurance.  In the event of an injury to my daughter/ward, any payment for medical attention is my responsibility.

SIGNATURE OF PARENT/GUARDIAN_____________________ DATE __________________