7/28/2019 Shine on Camp Registration and Liability Waiver

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SHINEONSPORTSLACROSSECAMP

REGISTRATIONANDWAIVERFORM*Parent/GuardianMUSTsendthisformtoSHINEONSportsorhavethisformpresentatregistrationtoparticipate.

ForMoreinfo,pleasevisitwww.shineonsports.comoremailnikkilieb@gmail.com.

CAMPERINFORMATIONFirstName: LastName:

Address: City,State,Zip:

DateofBirth: Age/Grade: Email: #yearsplayed:

USL#: T-ShirtSize:

PARENT/GUARDIANCONTACTINFORMATION

FirstName: LastName:

Cell#: Home#:

Email1: Email2: WAIVERANDRELEASEOFLIABILITY

SHINEONSportsisnotresponsibleforanyinjury(orlossorproperty)toanypersonsufferedwhileplaying,practicing,observing,orinany

otherwayinvolvedinthesportoflacrosseforanyreasonwhatsoever,includingordinarynegligenceonthepartoftheaboveortheiragentsoremployees.

Inconsiderationofmyparticipation,Iherebyagreetoindemnifyandholdharmlessanysponsor,theirrepresentatives,agents,employees,BoardofDirectors,officers,volunteers,referees,instructors,coachesoranyotherpersonorentityprovidingfields,property,servicesor

assistancefromandagainstanyandallpresentorfutureclaimsresultingfromanyaccidentornegligenceonthepartofsuchpersonsor

entities,forpropertydamage,personalinjury,orwrongfuldeath,arisingasaresultofmyparticipationinorreceivinginstructioninlacrosse

activitiesoranyactivitiesincidentalthereto,wherever,wheneverorhoweverthesamemayoccur.Iherebyvoluntarilywaiveanyandall

claimstherefrom,bothpresentandfuture.

Iamawarethatlacrosseisavigoroussportinvolvingseverecardiovascularstressandviolentphysicalcontact.Iunderstandthatlacrosse

involvescertainrisks,includingbutnotlimitedto;death,seriousneckandspinalinjuryresultingincompleteorpartialparalysis,brain

damage,andseriousinjurytovirtuallyallbones,joints,musclesandinternalorgansandthatequipmentprovidedformyprotectionmaybe

inadequatetopreventseriousinjury.Inaddition,Iunderstandthatparticipationinlacrosseinvolvesactivitiesincidentalthereto,including,

butnotlimitedto,traveltoandfromthesiteoftheactivity,participationatsitesthatmayberemotefromavailablemedicalassistance,and

thepossiblerecklessconductofotherparticipants.Iamvoluntarilyparticipatinginthisactivitywiththeknowledgeofthedangerinvolved

andherebyagreetoacceptanyandallinherentriskpropertydamage,personalinjuryordeath.Ifurtheragreetoindemnifyandhold

harmlessallofthepersonsandentitiesintheforegoingparagraphfromandagainstanyandallclaimsarisingasaresultomyparticipationinorreceivinginstructioninlacrosseactivitiesoranyactivitiesincidentalthereto,wherever,wheneverorhoweverthesamemayoccur.

IunderstandthatthiswaiverisintendedtobeasbroadandinclusiveaspermittedbythelawsofNorthCarolinaandagreethatifany

portionisheldinvalid,theremainderofthewaiverwillcontinueinfulllegalforceandeffect,Ifurtheraffirmthatthevenueandapplicable

lawforanylegalproceedingswillbetheStateofNorthCarolina.IaffirmthatIamoflegalage(18)andamfreelysigningthisagreementor,if

Iamunder18,myparentorlegalguardianisalsosigningit.Ihavereadandfullyunderstandthisagreementandthatbysigningthis

agreementIamgivinguplegalrightsorremediesthatmaybeavailabletome.

Iagreetofollowallcamprulesandallrulesofsafetycommontothesportoflacrosse.Iagreetoreportanyunsafepractices,conditions,or

equipmenttothemanagement.Icertifythat1)Ipossessasufficientdegreeofphysicalfitnesstosafelyparticipateinlacrosse,2)Iunderstand

thatIamtodiscontinueactivityatanytimeIfeelunduediscomfortorstress,and3)Iwillindicatebelowanyhealthrelatedconditionsthat

mightaffectmyabilitytoplaylacrosseandIwillimmediatelyverballyinformthemanagementifIfeelanydiscomfortorstress.

CIRCLE:

Diabetes HeartProblems Seizures Asthma Other:_________________________

Ihavereadandunderstandtheprecedinginformation.Iknow,understandandappreciatetherisksassociatedwithplayinglacrosseandIamvoluntarilyparticipatingintheactivity.Iassumealloftheinherentrisksoflacrosse,Iunderstandintheeventofamedicalemergency,an

EMSwillbecalledtorenderassistanceandthatIwillbefinanciallyresponsibleforanyexpensesinvolved.

_____________________________________________________________ ______________________________________________________________

NameofParticipant, Date SignatureofParentorGuardian, Date

HighSchoolCamp:(Rising5th-12thgrade):$180 YouthCamp:(Rising2nd-5hgrade):$85

PLEASEMAILTO:SHINEONSPORTS,145SPRINGLAKEDRIVE,PINEHURST,NC28374