аЯрЁБс>ўџ 24ўџџџ1џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС @ №ПЕbjbj0І0І (RЬRЬЕ џџџџџџˆ2222222Fъъъъ іFЖ„ † † † † † † $ЛR :Њ 2   Њ 22П     .22„   „   ќ 22H   а о~vЩъЛ v „ е 0 ,G1 FGH FF2222G2H <Zp@ А4фЉЊ Њ FFЄъw FFъ QUAKE LACROSSE, L.L.C. P.O. Box 722 Moorestown, NJ 08057 (856) 524-0989 AGE GROUP: (PLEASE CIRCLE SELECTION) 14 12 10 PLAYER INFORMATION: Player Name:_________________________________________________________________________ Address:_____________________________________________________________________________ City:___________________________________ ST:____________ Zip:_____________________ Home Phone:____________________________ Parent Cell:_________________________________ Parent Email:________________________________ Player Email:__________________________ Parents’ Names:________________________________________________________________________ Grade (as of 12/09):_____________ POS:_______________________ DOB/AGE:________________ Spring Program:___________________________________ Dominant Hand:__________________ U.S. Lacrosse # (mandatory):________________________________ Health Insurance Co:_________________________________ Policy #:_________________________ AMATEUR ATHLETIC MINOR WAIVER AND RELEASE OF LIABILITY In consideration of being allowed to participate in any way in the Quake Lacrosse athletics/sports program, and related events and activities, the undersigned: Agree that the parent(s) or legal guardian(s) will instruct the minor participant that prior to participation he should inspect the facilities and equipment to be used, and if the participant believes anything unsafe, should immediately advise his coach or supervisor of such condition(s) 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 and death, and severe social and economic losses which might result not only from their own actions, inactions, or negligence but the actions, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not known to us or not reasonably foreseeable at this time. Assume all the foregoing risk and accept responsibility for the damages following such injury, permanent disability or death. Release, waive, discharge and covenant not sue, QUAKE LACROSSE, its affiliated clubs, their respective administrators, directors, agents, coaches and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as “releasees”, from any and all liability to each of the undersigned, his or her heirs and the next of kin for any and all claims, demands, losses or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasees or otherwise. I give consent to have pictures, video footage and other similar media taken of the participant and agree that such media is the property of Quake Lacrosse and may be used to their discretion as needed. I agree to the refund policy. 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