Registration for MPAL Lacrosse
Adult #1 Name:_____________________________________
Address: ___________________________________________
___________________________________________
City: __________________________ State_______ Zip ________
Email:________________________________________________
Email #2: _____________________________________________
Home Phone:__________________ Bus. Phone:_______________
Cell Phone:______________________
Adult #2 Name:_____________________________________
Address: ___________________________________________
___________________________________________
City: __________________________ State_______ Zip ________
Email:________________________________________________
Email #2: _____________________________________________
Home Phone:__________________ Bus. Phone:_______________
Cell Phone:______________________
Child Name:___________________________________
Address:___________________________________________
____________________________________________
City:_______________________ State:_________ zip_________
D.O.B.:_________________ Gender (M/F):_____________
Age Group (*see Age Groups below):_____________
Medical Conditions:_________________________________________
Medications:_______________________________________________
Doctor:_____________________________ Phone:_________________
Insurance Carrier:____________________________________________
Insurance ID:___________________________
School:____________________________________ Grade:___________
Emergency Contact:__________________________ Phone:___________
Waiver:
I, the parent/guardian of the player(s) understand and accept the condition that the Manchester PAL and its staff will not be held liable and assume responsibilities for injuries and expenses incurred as a result of participation in this program. In the event of injury, PAL staff has my permission to provide or obtain medical care.
1. WAIVER & RELEASE: I am fully aware of and appreciate the risks, including the risks of catastrophic injury, paralysis and even death, as well as other damages and losses, associated with participation in a lacrosse event. I agree on behalf of myself, my heirs and personal representatives, that Manchester Police Athletic League, National Association of Police Athletic Leagues, New Hampshire Youth Lacrosse Association and its member chapters, and US Lacrosse, the host organization and the sponsor or sponsors with respect to a Covered Event, together with coaches, officials, volunteers, employees, agents, officers and directors of the host organization and any such sponsors shall not be held liable for any injury, loss of life or other loss or damage as a result of my participation in a Covered Event. This Waiver & Release shall also be for the benefit of and run in favor of any youth organization that requires participants to become members of US Lacrosse as a condition to their participation in such organization’s youth lacrosse events, which shall constitute Covered Events for purposes of this Waiver & Release, and any such youth lacrosse league shall constitute the host organization for such Covered Events.
2. MEDICAL ATTENTION: I hereby give my consent to MPAL and the host organization of any Covered Event to provide, through a medical staff of its choice, customary medical/athletic training attention, transportation and emergency services as warranted in the course of my participation in Covered Events.
3. READINESS TO COMPETE: I will only participate in those Covered Events in which I believe I am physically and psychologically prepared to compete.
4. CODE OF CONDUCT: I agree to all terms of the Manchester PAL, NHYLA and US Lacrosse.
Signed: ___________________________ Date: ____________________
Age Groups/Fees:
U9 Boys/Girls Ages 6-8 (Born 1/1/02 to 12/31/04) - $55
U11 Boys/Girls Ages 9-10 (Born 1/1/00 - 12/31/2001) - $105 ( $95 before 11/28/10, $115 after 1/31/11)
U13 Boys/Girls Ages 11-12 (Born 1/1/98 - 12/31/99) – $105 ($95 before 11/28/10, $115 after 1/31/11)
U15 Boys/Girls Ages 13-14 (Born 1/1/96 - 12/31/97) - $105 ($95 before 11/28/10, $115 after 1/31/11)
*Checks Payable to: MPAL Lacrosse
Mail forms and fee to:
MPAL Lacrosse
c/o Gary Sanchez
6 Star Cir.
Auburn, NH 03032