PLAYER PERMISSION FORM

BOYS' HIGH SCHOOL TEAMS INDOOR LACROSSE PROGRAM  2011-12

Please complete the following information legibly and have one of your parents or legal guardians sign and date it.  Return this completed form to your coach before you can participate.  Coach............Give this completed form (or a photocopy of it) to the Program Commissioner.

YOUR NAME (print) ____________________________________________________________

BIRTH DATE __________________________________    AGE ____________

TEAM OR ORGANIZATION NAME (be specific) ___________________________________________________

CIRCLE ONE:            VARSITY            JV

YOUR ADDRESS _____________________________________    CITY/TOWN _________________    ZIP ________

HOME TELEPHONE (include area code) __________________________________

E-MAIL ________________________________________________________

EMERGENCY CONTACT PERSON _________________________    PHONE ___________________________

LEAGUE AGREEMENT (to be read and signed by your parent/guardian)

I agree NOT to hold Fastbreak Lax, Inc., The Boys' High School Teams Indoor Lacrosse Program, Fastbreak Lax personnel, and its coaches responsible for any injury to my son/ward while playing in this indoor lacrosse program.  I further agree that my son/ward is in good physical health and is fit to play indoor lacrosse.  I also understand that this is a contact sport, and that my son/ward must wear the necessary and correct protective equipment to prevent serious injury.

I am aware that Fastbreak Lax, Inc. and Freestate Indoor Sports Arena do NOT provide health insurance for players.  In the event of an injury to my son/ward, any payment for medical attention is my responsibility.

PARENT/GUARDIAN SIGNATURE ____________________________________    DATE _________________________