| *Username: |
Please write down |
| *Password: |
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| *First Name: |
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| *Middle Initial : |
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| *Last Name: |
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| *Sex: |
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| Lax Nickname: |
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| *Address: |
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| *City: |
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| *State: |
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| *Zip: |
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| Daytime Phone: |
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| *Evening Phone: |
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| *Date of Birth: |
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| *School: |
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| *Current Grade: |
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| *High School Graduation Class: |
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| *High School Graduating From: |
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| *Position: |
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| *Lacrosse Experience: |
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| *Current Level of Lacrosse Play: |
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| US Lacrosse Membership #: |
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| Is your US Lacrosse Membership current?: |
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| What is your US Lacrosse Membership exp date?: |
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| *Email Address: |
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THIS SECTION TO BE COMPLETED BY A PARENT/GUARDIAN |
| *Parent Email Address: |
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| *Emergency Contact #: |
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| *Fathers Name: |
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| *Mothers Name: |
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| If you are registering as an individual on a team, please enter your team name here: |
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| *By selecting YES I wish to receive email notifications of upcoming events sponsored, co-sponsored, or supported by NCLA. (NCLA respects the right of privacy of NCLA registered persons. NCLA does not give or sell the information to third party vendors without authorization from registered person.) |
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| *By selecting YES I authorize permission to NCLA to provide my contact information to universities or colleges that support lacrosse programs and for the purpose of a lacrosse coach having the ability to contact me or recruit me. |
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*I am fully aware of and appreciate the risks associated with participation in a lacrosse event, including the risk of injury and death, as well as other types of damages and loss. I further agree on behalf of my child that the host organizations and sponsors, along with their coaches, volunteers, agents of these organizations shall not be liable for any injury, loss of life or other loss or damage occurring as a result of the participation in the event. My signature below is my acknowledgement that I have read and understood every provision of this Waiver and Release of Liability, and that I agree to abide by it.
"By selecting YES I authorize the equivalence of my handwritten signature and date as well as indicate my authorization approval of aforementioned liability waiver." |
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Enter Security Code:
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