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2008  WINTER LACROSSE LEAGUE REGISTRATION FORM 

  PLEASE COMPLETE THE FOLLOWING AND RETURN THE COMPLETED FORM WITH PAYMENT MADE PAYABLE TO:

                                    Ocean State Lacrose Club   88 Aaron Ave.     Bristol, RI     02809

Name _________________________________ D.O.B.:____________ Grade______School ______________________

Address__________________________________________  City______________________  St_____  Zip__________

US Lacrosse Membership #______________________E-Mail______________________________________________

Parents’ Names_____________________________________________________Phone # (H)_______________(W)___________

Emergency Contact Person: ______________________________________ Phone # ______________Cell  Phone #___________

Height_______ Weight________Experience (Years)___________ Awards_____________________________________

Special Requests___________________________________________________________________________________________

                                                                                              Boys                                                                  Girls

Middle School Player Fee                           $160 ______  GOALIE  $80  _____                 $160  ______  GOALIE  $80 _____

Grade School Player Fee                           $130 ______  GOALIE  $60  _____                 $130  ______  GOALIE  $60 _____

JERSEY SIZE: (circle one)     Y-L    A-S     A-M      A-L      A-XL    

Are you available to help out as a coach, administrator, official, or score/time keeper?  _______ Yes      _______ No                                                                                                                                                                                                   

Insurance Carrier______________________________________________________ Policy #___________________________

Physician Name__________________________________________________Phone #_________________________

Does your child have any physical problems, allergies or illnesses which we should be aware of?  Y/n   if yes, please explain in detail.

_________________________________________________________________________________________________________

In consideration of being allowed to participate in any way in the Ocean State Lacrosse Club, hereafter referred to as OSLC, and any related activities sponsored by OSLC, the undersigned acknowledges and fully understands that each participant will be engaged in activities that involve risk of serious injury, including permanent disability, death, and severe social and economic losses which might result  from his (her) actions, inactions or negligence of others, the rules of play, or the conditions of the premises or of any of the equipment used.  Furthermore, there may be other risks not known to the league or not reasonably foreseeable at this time.  The undersigned assumes all the foregoing risks and accepts personal responsibility for the damages following such injury, permanent disability, or death. The undersigned hereby agrees to absolve, release, waive, discharge, and hold harmless the OSLC, its respective administrators, directors, agents, coaches, and other employees of the organization conducting games, clinics and or practices from demands, losses, or damages on account of injury including death or injury caused or alleged to be caused in whole or in part by the negligence of the releasees or otherwise.  Furthermore, I hereby give my permission to OSLC, and all persons and entities authorized by it, to use for promotional and other purposes, my name and any photograph, motion pictures, video tape or other reproduction taken of me during or in conjunction with OSLC.

I, the parent/legal guardian of the above named player, hereby give my permission for my child____________________ to participate in any and all activities offered by OSLC in 2007-2008. I assume all risks and hazards incidental to such participation including transportation to and from all activities. I also agree to waive, release, absolve, indemnify and hold harmless the OSLC organizers, directors, supervisors, coaches, participants, designated officials, field facilities and persons transporting my child to and/or from OSLC from any claim or action arising from any injury to my child. Finally, I agree to abide by the Ocean State Lacrosse Parent’s Code of Conduct at all OSLC sponsored events.

I further hereby give my consent for my child ______________________________ to receive emergency medical treatment which may be deemed advisable in the event of an accident or illness while participating in OSLC sponsored events.  I understand that, if possible, I will be notified by telephone of any emergency.

The Undersigned has read the above waiver and release, understands that he/she has given up substantial rights by signing it, and signs it voluntarily.

PARENT OR GUARDIAN'S SIGNATURE: ___________________________________DATE:_______

 For more information, go to www.oceanlax.com or call Jeffrey Popham, the OSLC Director, @ (401) 247-1003.