Old North State Lacrosse School
Waiver Form

In consideration of my participation in the Old North State Lacrosse School, Inc. instructional programs, I agree to the following:

1. Waiver and Release: I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis and even death, as well as other damages and losses, associated with participation in a lacrosse event and related sports conditioning activities. I further agree on behalf of myself, my heirs, and personal representatives, that Old North State Lacrosse School, Inc., along with its coaches, officials, referees, umpires, volunteers, employees, agents, officers and directors, of these organizations, shall not be liable for any injury, loss of life, or other loss or damage occurring as a result of my participation in the event.

2. Medical Attention: I hereby give my consent to Old North State Lacrosse School, Inc. to provide , through a medical staff of its choice, customary medical/athletic training attention, transportation, and emergency medical services as warranted in the course of my participation in Old North State Lacrosse School sponsored or sanctioned events.

3. Readiness to Compete: I will only participate in those competitions or activities in which I believe I am physically and psychologically prepared to participate.

4. Code of Conduct: I have read and agree to all the terms in the Code of Conduct on the second page of this form, especially with regard to my responsibilities as a Player.

Participant Primary Medical Insurance Carrier
Policy Number
   

Signature of Participant Print Name of Participant
Date
     

FOR ANY PARTICIPANT WHO IS NOT YET 18 YEARS OLD: As legal guardian of this participant, I hereby verify by my signature below that I have read and fully understand each of the above conditions for permitting my child to participate in Old North State Lacrosse School, Inc. instructional programs and leagues, and I accept each of the above conditions, especially the waiver and release set forth in paragraph one.

Signature of Parent/Guardian Print Name of Parent/Guardian
Date
     

 

For further information call or write:

The Old North State Lacrosse School
P.O. Box 2254
Jamestown, NC 27282
Phone (336) 454-2904
(919) 363-9367 • (919) 858-9344
http://www.nclax.com/oldnorthstate

©2007 Old North State Lacrosse School