Insurance Form

Fill out the form below.
All athletes must fill out BOTH a Registration Form and Insurance Waiver Form.
If you would like to print the Insurance Form and hand it in, you can download it here.
 
STATEN ISLAND LACROSSE
WAIVER AND RELEASE LIABILITY
In consideration of being allowed to participate in any way in the STATEN ISLAND LACROSSE PROGRAMS. and related events and activities, the undersigned: Agree that the parent(s) or legal guardian(s) will instruct the participant that prior to participating he or she should inspect the facilities and equipment to be used, and if the participant believes anything is unsafe he or she should immediately advise his or her coach or supervisor of such conditions and refuse to participate, acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability, death, and severe social and economical losses which might result from not only their actions or negligence but the actions or negligence of others, the rules of play, or the conditions of the premises or of any equipment used. Photography, video, or other related media taken at an STATEN ISLAND LACROSSE event is property of STATEN ISLAND LACROSSE INC., and may be used in future advertisements, website, or any other form of display promotion. Assume all foregoing risk and accept personal responsibility for damages following such injury, permanent disability or death. Release, waive, discharge and covenant not sue STATEN ISLAND LACROSSE, its affiliated clubs, their respective administrators, directors, agents, coaches, and other employees of the organization, other participants sponsoring agencies, owners and lease of premises used to conduct the event, all of which are hereinafter referred to as ” releases “ from any next of kin for any claims, demands, losses or damages to property, caused or alleged to be caused in whole or in part by negligence of the releases or otherwise.
 

I HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTOOD THAT I/WE HAVEN GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY (required)
 I AGREE

Parent/Guardian Name

Date

Parent/Guardian Relationship to Athlete

Athlete Name

Athlete Date of Birth

Athlete Age

Telephone Number

Email