FASTBREAK LAX, INC.   

(Office)    8050 Old Montgomery Rd  Ellicott City, MD 21043

(Office)  410-908-4567 or 410-931-2331    (Fax)  443-283-4011

PLAYER PERMISSION FORM FOR GIRLS' YOUTH INDOOR LACROSSE PROGRAM   2011-12

PARENT OR LEGAL GUARDIAN:  Complete the following information legibly and sign it below.  Return this completed form to your child's coach before your son can participate.  COACH:  Give this completed form, or a photocopy of it, to the Program Commissioner before the player named below can participate.

PLAYER'S NAME (print) ____________________________________

BIRTH DATE _________________________________________        AGE __________

TEAM OR ORGANIZATION NAME (be specific) __________________________________________________

CHOOSE ONE:    TYKER_____      LIGHTNING_____      MIDGET_____      JUNIOR_____

HOME ADDRESS ______________________________________    CITY/TOWN _________________    ZIP____________

HOME TELEPHONE (include area code) _________________________   E-MAIL _________________________________

EMERGENCY CONTACT PERSON __________________________    EMERGENCY PHONE   _______________________

LEAGUE AGREEMENT (to be read and signed by the player's parent or legal guardian)

I agree NOT to hold Fastbreak Lax, Inc., the Girls' Youth Indoor Lacrosse Program, Fastbreak Lax, Inc. personnel, and its coaches responsible for any injury to my daughter/ward while playing in this indoor lacrosse program.  I further agree that my daughter/ward is in good physical health and is fit to play indoor lacrosse.  I also understand that my daughter/ward must wear the necessary and correct protective equipment ( to include mouth guard and goggles ) to prevent serious injury, and that this equipment is in good to excellent shape.

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 daughter/ward, any payment for medical attention is my responsibility.

PARENT / GUARDIAN SIGNATURE _____________________________________    DATE _________________________