Box League

GLC BOX LEAGUE REGISTRATION FORM

Mail Form & Payment to the GLC Lacrosse:
Justin Cutter
9329 Aster Ave.
St. Louis MO 63123
Questions: (314) 537-0805
Email: lee01cutter@yahoo.com

Player Name: _______________________________.
Address: ________________________________________________________.
Home Phone: ___________________. Mobile phone: _____________________.
Position: . Grade:___ .
School: .
E-Mail :_______________________________
Parent Name :____________________________
US Lacrosse #:

Definitive Emergency Medical Care Consent
I (We), the undersigned parent(s)/legal guardian(s) of :_____________________ ____________________ do hereby consent to have prompt definitive emergency medical care administered to the aforementioned member of my (our) family in my (our) absence. In so doing, I (We) release the administering facility and/or individual from responsibility for medical services performed. The Samurai Lacrosse Program and/or its team members and representatives are hereby resolved from responsibility for subsequent consequences occurring there from. If necessary, contact our son’s doctor:
Doctor’s name -
Office Phone # – After Hours # -
Insurance Carrier and Policy Number:
If I (We) cannot be reached, in case of emergency call:
______________________________________ ________________________
Name/relationship to player Phone number

Liability Release:
I give permission to the GLC Lacrosse staff to act for me in an emergency requiring medical attention. I release the organization and its volunteers from any liability for any injuries that might be incurred during this league. I understand that lacrosse is a physical game and severe injury or even death could result from my child’s participation.

_____________________________________ Parent or Guardian’s Signature