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Individual Player Waiver- Must be completed by all participants

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Birthdate:

* Grade:

PARENT/GUARDIAN

* Firstname:

* Lastname:

* Cell Phone:

* Parent, Guardian or Adult E-mail:

* Phone:

* I:

hearby wish to register in the Brookhaven Town Youth Lacrosse Program. By signing this card, I subject myself to the rules and regulations governing play in the Town of Brookhaven Youth Lacrosse Program. Violations of these rules and regulations may result in disciplinary action against me.

*** Insert your waiver information here ***

I/we agree with the above *

* indicates required fields