Youth Online Waiver/Release Form

Athlete Information

Athlete's Name*

First NameLast Name

(Add.) Athlete's Name

First NameLast Name

(Add.) Athlete's Name

First NameLast Name

Birth Date*

MonthDayYear

(Add.) Birth Date

MonthDayYear

(Add.) Birth Date

MonthDayYear

Grade Level*

Grade Level

(Add.) Grade Level

Grade Level

(Add.) Grade Level

Grade Level

Schools*

Name of school/s

Gender*

(Add.) Gender

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How did you hear about us?*

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

Area CodePhone Number

E-mail*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Does the athlete take any medication on daily basis? If yes, please list medication.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Roe Pro Fitness & Athletics during the selected clinic. In exchange for the acceptance of said child’s candidacy by Roe Pro Fitness & Athletics., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Roe Pro Fitness & Athletics all its respective coaches, volunteers, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected clinic sessions.

In case of injury to said child, I hereby waive all claims against Roe Pro Fitness & Athletics including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for my child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Roe Pro Fitness & Athletics and its affiliates including Trainers, Coaches, and Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered training.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Media Release

I grant permission to Roe Pro Fitness & Athletics and/or Dodge City Lacrosse to use my (son/daughter) image (photographs and/or video) for use in Roe Pro Fitness & Athletics publications including videos, email blasts, recruiting biographies, and to use my image in electronic versions of the same publications or on the Roe Pro Fitness & Athletics and/or Dodge City Lacrosse website or other electronic forms of media.

Projected First Class Date*

Date

Projected First Class (Title/Time)*

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Parent/Guardian's Signature*