Please Print and Sign this document, and bring it with your $25.00 registration fee to your first Clinic or Tryouts.

Participant's Name   *     Birthdate *
Street Address         *    City   *    Zip   *
EMERGENCY INFORMATION
Father       Phone     Wk Phone      Cell  
Mother     Phone     Wk Phone     Cell   
In an emergency when parent/guardian cannot be reaced, please contact the following:
Name       Phone      Cell  
Name       Phone      Cell  
Allergies  
Other Medical Conditions  
Physician       Bus Phone  
Medical Insurance      Phone  
Policy Holder Name   
Policy / Group Number   
*** PLEASE REVIEW THE FOLLOWING BEFORE SIGNING ***
THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT MUST BE COMPLETED BEFORE A PLAYER/YOUTH BEGINS PARTICIPATION IN ANY LADY CATS PROGRAM. TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDED HEREIN.
I, the parent/guardian of the minor applicant/participant, acknowledge and fully understand that each applicant/participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, and I assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, and I hereby release, discharge, covenant to indemnify and not to sue The Lady Cats of Libertyville, its affiliated organizations and sponsors, their coaches, managers, employees and associated personnel, officers, directors, agents, including the owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the Lady Cats Programs and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize. The applicant/participant has received a physical examination by a physician and has been found physically capable of participating in the Lady Cats Programs. I hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I also agree to save and hold harmless and indemnify each and all parties herein referred to above as released from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasee because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasee. I have read the above waiver/release and understand that I have given up substantial rights by signing this release and sign below voluntarily.
 
Signature: ________________________________ Date: ________