Bnys O Youth O High Schsol O Po$'Collegiate
!.*$
lileress* &atianal ]le$dqrrertsgs
1
13 West Universrty Parkway Baltimore, Maryland 21210-3300 . ph: 410.235.6882 .
'
I
SIEP
_ _
l5
and rrnder
Hiqh School:
_
Ensrre you get all benefits by lnaintallllflg a current email address
- Select your membelship category based on yoffi age
Youlh:
Adult: Ages
-
not HS. player
$25
,...
$35
lB and uttder
18+...
.
.
:.
. . ..
.. .
-
.
...
E}IROTTMEIIT fORM AIID MEMBER AGREEMEI{T lnsuranse lnformation All categories except "Fan" include comprehensive secondary lacrose insurance and
.S5B
must sign below. lnsurance information, including claim forms, can be {ound 0n our
SIEP 2 - Select all catc$ories whcrc you padicipate:
websitg: lwvw.uslacrose.org.
ideflily eacll caleg0ry 0l participalioll l0 0blain illsururlcs c0lerage for
(You rllust
\ Signature Required lor Acceptance of Membership
thal caleUory, Ihere is no addilional charge l0r rnulliple categories) PTAYER
_ -
ln consideration of my membership in US Lacrose, and my participation in US Laclosse
C0ACH (Check all that apply) tvlef
s
O
Yauth
C
*For
O O O O O O O
sanctioned, recognized 0r sponsored events ("Covered Evenls"), I agtee t0 the following:
V/olnen's
O
JV/Varsrty O HS JV Head Coach O HS Vasrty Head Coach O O lJS Club Coliele Club O O Colege Assi$ant O CoJlege Vasily Head O Posl-Collegrate Club HS Assrsta"t
for
Yorth
1.
Waiver and Helease: I am fully aware of and appreciate the risks, including the risks
llS Asrstanl f:r JV/Va'srlv
0f catastlophic injury, paralysis and even death, as well as other damages and loses,
HS JV l']ead Coach
asocialed with participation in a lacrose event. I agree on behalf of myself, my hein
[lS Varsty llead Coach
and personal representatives, that US Lacrose, the host organization and the sponsor
l.jS Ciub
or sponsors wilh respect l0 a Covered Event, logether with coaches, officials, v0lunteers,
College Club
employees, agents, officers and directors of the host organization and any such spons0rs
Colhqe Assntant
shall not be held liable for any injury,
College Varsity Head
my participation in a Coyered ,Event. This Waiver & Release shall also be for the benefit
PcslCcilegiate Ciub
of and run in favor of any yo'uth organizati0n that requires participants to become
of lile 0r other loss 0r damage as a result 0f
youth lacrose events, which shall constitute Covered Events for purposes 0f this Waiver
www.uslacrosse.org/cep.
0FFlGlAt (Check all that apply)
lr,tlen/Bnys O Youth O High Schsol O Po$'Collegiate lf you are a college official or assignor contact US l.acrose for the appropriah form [nter your Distrlci Number
& Release, and any such youth lacrose league shall constitute the host organization for such Covered Events.
Womeni 0lrls'
O
2. Medical Aftention: I hereby give my consent t0 US l-acrose ard'fte ho$ organization of
O Apprertice O Local
any 0wered Event to provide, through a medical staff of its choice, customary medi-
callalhletic training attention, transpofiation and emergency services as waranted in the
lf yoLrr rmpire level is drstricl
course of my participation in Covered Events.
or hlgher, contact US Lacrose for the alpr0priate f0rm
3. Readiness to Compete: I will only participate in those Covered Events in which I believe I am physically and psychologically prepared t0 compete.
[nter your Local Eoard
4. lnlormation Certification: ollhial caletory membersihs
ettpire
I
Youth
(Contact US L:crosse if you do not know your drstrlct or board) All
los
members of US Lacrosse as a condilion t0 their participation in such organization's
inlormation on becoming a GEP certilied coach please visit:
_
fax: 41b.843.0390 -:
I
certify that all information provided by me in this
application, including without limitation my membership category, is lrue, accurate
3i30, regardhss 0f date joinBd,
and complete and I understand that any untrue, inaccurate or incomplete statement
or information will automatically invalidate my membership and all of the benefits of 0fficiais and coaches receive one rulebcok complimentary and may plrchase additjonal rulebook at SB sach Plcass indicale number
_l\,{ens
NCAA
_Mens
HS/Youth
_
FAil (ior
(Federation) _Women's
y6
@
mormation:
Please consider a
ler
pa.d to yoLr locar Snaple' ccvet
tarr]educlble gift to support the
EnCosed (oayabre ro
infomation
0ate
Nanre on Card
_
Policy Number:
lf
S
participant is under 18, lhen a parent or legal guardian of this participant must sign.
As member, or as parent or legal guardian of a member under 18, I hereby verify by my signature below that I fully understand and accept eac{ of the above conditions.
Signature:
0ate:
bS Lauosse)
[rcdit Card Card Nrmber: Expiration
o
gr0r44h 0f lacrosse natronr44del
Yo[r iotal Fee
Payment lnlormation:
$ecr
tg yo,r i
(see u/e3s re l0r irsrrg):
S
SIEP 3 - Gomplete your payment
O O
accepted US Lacrose/Positive Coaching Alliance Code of Conduct).
SB each
Padicipant Primary Medical lnsurance Carrier is:
r' rlrs w t be
cndc .l{ess yoJ ,rd,cate a d flcrcrt [hapte'
llS Lalrcse I'urd
_
5. Gode ol Conduct: I agree to all lerms on the reverse side of this form (refen to
NCAA
HS/Yodh (USL)
members who do not pa(ir:ipate as a player coach or otficial)
Chapt& lntormation: A portrcn 6i
Ourih[U
frr each type:
_Womens
Total additional rulebortks purchased
membership in US Lacrose.
Printed ltlame of signor:
I
(rf d fferent thar abow):
Address (rf drfferenl than above)
Membership is annual and,non-refundable We suggest you renew online for the faslest and most efficient process: www.uslacrose.org.
SIEP 4 - Pleas8 sign waiuer
lo the dght
wE708 100w608
lileress* &atianal ]le$dqrrertsgs
1
13 West Universrty Parkway Baltimore, Maryland 21210-3300 . ph: 410.235.6882 .
'
I
SIEP
_ _
l5
and rrnder
Hiqh School:
_
Ensrre you get all benefits by lnaintallllflg a current email address
- Select your membelship category based on yoffi age
Youlh:
Adult: Ages
-
not HS. player
$25
,...
$35
lB and uttder
18+...
.
.
:.
. . ..
.. .
-
.
...
E}IROTTMEIIT fORM AIID MEMBER AGREEMEI{T lnsuranse lnformation All categories except "Fan" include comprehensive secondary lacrose insurance and
.S5B
must sign below. lnsurance information, including claim forms, can be {ound 0n our
SIEP 2 - Select all catc$ories whcrc you padicipate:
websitg: lwvw.uslacrose.org.
ideflily eacll caleg0ry 0l participalioll l0 0blain illsururlcs c0lerage for
(You rllust
\ Signature Required lor Acceptance of Membership
thal caleUory, Ihere is no addilional charge l0r rnulliple categories) PTAYER
_ -
ln consideration of my membership in US Lacrose, and my participation in US Laclosse
C0ACH (Check all that apply) tvlef
s
O
Yauth
C
*For
O O O O O O O
sanctioned, recognized 0r sponsored events ("Covered Evenls"), I agtee t0 the following:
V/olnen's
O
JV/Varsrty O HS JV Head Coach O HS Vasrty Head Coach O O lJS Club Coliele Club O O Colege Assi$ant O CoJlege Vasily Head O Posl-Collegrate Club HS Assrsta"t
for
Yorth
1.
Waiver and Helease: I am fully aware of and appreciate the risks, including the risks
llS Asrstanl f:r JV/Va'srlv
0f catastlophic injury, paralysis and even death, as well as other damages and loses,
HS JV l']ead Coach
asocialed with participation in a lacrose event. I agree on behalf of myself, my hein
[lS Varsty llead Coach
and personal representatives, that US Lacrose, the host organization and the sponsor
l.jS Ciub
or sponsors wilh respect l0 a Covered Event, logether with coaches, officials, v0lunteers,
College Club
employees, agents, officers and directors of the host organization and any such spons0rs
Colhqe Assntant
shall not be held liable for any injury,
College Varsity Head
my participation in a Coyered ,Event. This Waiver & Release shall also be for the benefit
PcslCcilegiate Ciub
of and run in favor of any yo'uth organizati0n that requires participants to become
of lile 0r other loss 0r damage as a result 0f
youth lacrose events, which shall constitute Covered Events for purposes 0f this Waiver
www.uslacrosse.org/cep.
0FFlGlAt (Check all that apply)
lr,tlen/Bnys O Youth O High Schsol O Po$'Collegiate lf you are a college official or assignor contact US l.acrose for the appropriah form [nter your Distrlci Number
& Release, and any such youth lacrose league shall constitute the host organization for such Covered Events.
Womeni 0lrls'
O
2. Medical Aftention: I hereby give my consent t0 US l-acrose ard'fte ho$ organization of
O Apprertice O Local
any 0wered Event to provide, through a medical staff of its choice, customary medi-
callalhletic training attention, transpofiation and emergency services as waranted in the
lf yoLrr rmpire level is drstricl
course of my participation in Covered Events.
or hlgher, contact US Lacrose for the alpr0priate f0rm
3. Readiness to Compete: I will only participate in those Covered Events in which I believe I am physically and psychologically prepared t0 compete.
[nter your Local Eoard
4. lnlormation Certification: ollhial caletory membersihs
ettpire
I
Youth
(Contact US L:crosse if you do not know your drstrlct or board) All
los
members of US Lacrosse as a condilion t0 their participation in such organization's
inlormation on becoming a GEP certilied coach please visit:
_
fax: 41b.843.0390 -:
I
certify that all information provided by me in this
application, including without limitation my membership category, is lrue, accurate
3i30, regardhss 0f date joinBd,
and complete and I understand that any untrue, inaccurate or incomplete statement
or information will automatically invalidate my membership and all of the benefits of 0fficiais and coaches receive one rulebcok complimentary and may plrchase additjonal rulebook at SB sach Plcass indicale number
_l\,{ens
NCAA
_Mens
HS/Youth
_
FAil (ior
(Federation) _Women's
y6
@
mormation:
Please consider a
ler
pa.d to yoLr locar Snaple' ccvet
tarr]educlble gift to support the
EnCosed (oayabre ro
infomation
0ate
Nanre on Card
_
Policy Number:
lf
S
participant is under 18, lhen a parent or legal guardian of this participant must sign.
As member, or as parent or legal guardian of a member under 18, I hereby verify by my signature below that I fully understand and accept eac{ of the above conditions.
Signature:
0ate:
bS Lauosse)
[rcdit Card Card Nrmber: Expiration
o
gr0r44h 0f lacrosse natronr44del
Yo[r iotal Fee
Payment lnlormation:
$ecr
tg yo,r i
(see u/e3s re l0r irsrrg):
S
SIEP 3 - Gomplete your payment
O O
accepted US Lacrose/Positive Coaching Alliance Code of Conduct).
SB each
Padicipant Primary Medical lnsurance Carrier is:
r' rlrs w t be
cndc .l{ess yoJ ,rd,cate a d flcrcrt [hapte'
llS Lalrcse I'urd
_
5. Gode ol Conduct: I agree to all lerms on the reverse side of this form (refen to
NCAA
HS/Yodh (USL)
members who do not pa(ir:ipate as a player coach or otficial)
Chapt& lntormation: A portrcn 6i
Ourih[U
frr each type:
_Womens
Total additional rulebortks purchased
membership in US Lacrose.
Printed ltlame of signor:
I
(rf d fferent thar abow):
Address (rf drfferenl than above)
Membership is annual and,non-refundable We suggest you renew online for the faslest and most efficient process: www.uslacrose.org.
SIEP 4 - Pleas8 sign waiuer
lo the dght
wE708 100w608
