right to place individuals on teams to ensure everyone has a place

to play.

teams with a defined coach.

boys games that day

registering with a team, please leave empty and individual players

will be placed on open teams.

currently not certified, a training course will be offered by WMLOA in advance of the fall ball

and as plans are made you will be added to the appropriate distribution list. Officials must be

limit the number of officials.

Name: ________________________________ Birth date: __________ Grade: ______

Address: _______________________________ City: _______________ Zip: __________________

Home Phone: ___________________________ Cell Phone: ________________________________

E-Mail(s): _________________________________________________________________________

Parent/Guardian Names: ____________________________________________________________

Parent/Guardian Cell Phone(s):_______________________________________________________

Emergency Contact & phone: ________________________________________________________

School: ________________________________ Years of Lacrosse Experience: _____

Team: _________________________________ Coach: ____________________________________

Western Maryland Chapter of US Lacrosse Waiver of Liability 2008

In signing this waiver, I release the Western Maryland Chapter of US Lacrosse, Frederick County

Public Schools and the directors and coaches of the Western Maryland Chapter of US Lacrosse

Fall Ball Program and other involved parties from any claims or responsibility for injuries

suffered in the league. I knowingly assume all risks associated with participation, even if arising

from the negligence of the participants or others, and assume FULL responsibility for my

participation. I certify that I am in good physical condition and can participate in Fall Ball.

Further, I authorize the site director to request medial treatment as necessary to insure my well

being. I have my own medical insurance.

Athlete: ________________________________________ Date: _________________________

Parent/Guardian _________________________________ Date: _________________________

Heath Insurance Provider: ________________________

Policy #: _______________________________________ Group #:______________________