ࡱ> 796[ bjbj .ΐΐ || 4666666$OZZo)))"4)4))0EWv?" 0,av00") <ZZR| : Scranton Fall 7v7 Waiver and Release Form Sponsored by: Atlantic Elite Lacrosse, LLC (A.E. Lacrosse LLC) Please Read Before Signing In consideration of being allowed to participate in any way in the Scranton Fall 7v7 tournament (sponsored by A.E. Lacrosse, LLC) and its events and activities, the undersigned acknowledges, appreciates and agrees that: The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury or death does exist; and, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my participation; and, I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS THE SCRANTON MINI CAMP (A.E. Lacrosse, LLC,) their officers, agents and/or employees, other participants sponsoring agencies, sponsors, advertisers, and id applicable, owners and lessors of premises (University of Scranton,) WITH RESPECT TO ANY AND ALL INJURY, DISABILITY DEATH, or loss or damage to personal property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASORS OR OTHERWISE. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, I FULLY UNDERSTAND ITS TERMS, I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANDY INDUCEMENT. APPLICANTS SIGNATURE (PARENT/GUARDIAN IF UNDER 18) DATE MEDICAL FORM Allergies____________________________________________________________ Current medications _______________________________________________ Physical limitations ________________________________________________ Date of last tetanus shot __________________________ Comments or special problems_______________________________________________ Campers Insurance Carrier and policy number__________________________________ Telephone number where family can be reached in case of an emergency while campers are at an A.E. Lacrosse Event ( ) ______________________ In the event that a family member cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for the camper named above. I CERTIFY THAT I __________________________ AM PHYSICALLY FIT TO ACTIVELY PARTICIPATE IN ALL LACROSSE CAMP ACTIVITIES. 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