East End Girls Lacrosse

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A Program of the East End Athletic Association of Pittsburgh
Spring, 2015

Player Name *

Player’s Date of Birth *

YYYY

Player Grade *

Player Home Address *

Player Home Phone Number

Player School *

Parent/Guardian #1 *

Parent/Guardian #1 EMAIL ADDRESS *

Parent/Guardian #1 CELL PHONE *

Parent/Guardian #2 EMAIL ADDRESS

Parent/Guardian #2 CELL PHONE

Emergency Contact *

Emergency Contact - Relation to Player *

Emergency Contact PHONE # *

I hereby grant permission for the above-named player (the “Player”) to participate in the East End Lacrosse Program of the East End Athletic Association of Pittsburgh. I represent that the Player has appropriate and adequate medical insurance coverage. In consideration of the Player being allowed to participate in the Program, and intending to be legally bound, I do hereby release the East End Athletic Association of Pittsburgh, its administrators, officers, coaches and other agents from any actions or claims I/we or the Player might hereafter have by reason of the Player’s participation in the Program. *

Click box to agree to waiver

I am a legal parent/guardian of the above named player and I agree to the above waiver

Required

Are you a US Lacrosse member?

Enter Player's USLacrosse #

Player T-Shirt Size *

Player Reversible Pinnie Size (these run small, will be used for games, may require layers underneath) *

Player Mesh Short Size *

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