Section 1: Parent/Guardian Info

Parent/Guardian 1 (main contact)

Parent/Guardian 2 (secondary/optional contact)

Section 2: Child Info

Game(s) Child Would Like to Learn/Play: *
Boys' Game Equipment Child Would Like to Borrow:
Girls' Game Equipment Child Would Like to Borrow:
Is child allergic to any drug, insect bite, food or other substance? *
Is child taking any medication (prescribed or over-the-counter)? *
Does child have any conditions requiring special attention, such as ADHD, asthma or other respiratory conditions, autoimmune disorder, bleeding disorder, diabetes, epilepsy, heart disease, musculoskeletal disorders, mood disorders or other mental health conditions, neurologic disorders or history of head/neck/back injury, etc.? *
Do you have any concerns about the child's participation? *

Section 3: Additional Emergency Contact

In case of an emergency, we will contact the parent(s)/guardian(s) listed above. If we cannot get in touch with one/both of those primary contacts, please provide an additional contact we should try.

Section 4: Agreements, Releases and Waivers

The clinic may provide participants with loaned/borrowed equipment so children can try lacrosse without having the financial burden of purchasing equipment. I acknowledge my child may receive and/or use equipment during the clinic that is on loan or borrowed. I will be financially responsible for costs associated with repair and/or replacement for any loaned/borrowed equipment that is damaged, lost or not returned due to my child's negligence or misconduct. *
I understand Blaze Lacrosse Club may capture and edit photographs and/or video footage of my child participating in the clinic. I permit Blaze Lacrosse Club to use said imagery in its advertising, including but not limited to its website, social media channels, other electronic media and print media, without any expectation or right of prior approval, payment or other consideration. Blaze Lacrosse Club may reference my child's first name with the image usage, but may not reference my child's last name. *
I understand Blaze Lacrosse Club will use the information provided herein to confirm and manage its roster with USA Lacrosse. Blaze Lacrosse Club may also share my child's information with their school, upon the school's request, for transportation and/or student safety purposes. Blaze Lacrosse Club will not use our information for any other purpose not expressly stated in this agreement and will not sell, rent or otherwise provide this information to any other third party. *
I permit Blaze Lacrosse Club to share my contact information and demographic information about my child with Central Susquehanna Lacrosse Club and any similar, lacrosse-related entity for the sole purpose of lacrosse-related communications and playing/learning opportunities available. *
Should a medical emergency arise during my child's participation, I understand that reasonable efforts will be made to contact me, the secondary parent/guardian if provided and the emergency contact provided. If none of the contacts can be reached, or if it is believed that my child's life or health may be adversely affected by the delay that contact attempts would cause, I consent to the administration of medical treatment, including but not limited to life-sustaining measures and/or surgical procedures, deemed necessary by the medical professionals/facility chosen by Blaze Lacrosse Club or Emergency Services personnel. *
I understand and acknowledge that participation in this clinic comes with inherent risks, including but not limited to athletic injuries and illness from exposure to viruses and/or bacteria, and voluntarily assume such risks. I understand Blaze Lacrosse Club and its officers, directors, employees, volunteers, agents, representatives and insurers will undertake reasonable safety efforts. I certify my child is in good health and has no conditions or impairments which would preclude safe participation in the clinic. I agree to notify Blaze Lacrosse Club of any changes in health status that may place my child at a greater degree of risk. I, on behalf of myself and my child, my heirs, representatives, executors, administrators and assigns, release and hold harmless Blaze Lacrosse Club and its officers, directors, employees, volunteers, agents, representatives and insurers from any causes of action, claims or demands of any nature beyond what is covered under the USA Lacrosse Insurance Program now or in the future. *
I understand that participants will be asked to sign a code of conduct during the clinics, and that any participant consistently unable to participate under the conduct guidelines may be removed from the program without refunding the USA Lacrosse membership. *

Section 5: Electronic Signature