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14

Jan, 2018

GVSU WInter Wonderlax

Gvsu 5v5 winter wonderlax
Indoor lacrosse tournament
Please return this completed portion with your $55 payment prior to January 26, 2018. If coming as a team, please give your registration form to the group
organizer/coach so they can submit the forms in one group.
GVSU 5v5 Registration Form

Name: _______________________________________________________ Email: _________________________________________________
Address: _____________________________________________________ Phone: _________________________________________________

 _____________________________________________________ Grade: _________________ Position: ______________________
School: ______________________________________________________ Level/Experience _____________ Age: __________________
5v5 Tournament Team Name: _______________________________________________________________________________________
Waiver of Liability: As the parent/guardian of the camper listed above I hereby agree to the following as a condition of _________________________________________’s participation in the Grand Valley State
University (GVSU) 5v5 WinterWonderLax. I give my permission to GVSU, St. Mary’s Hospital, Spectrum Health Care System, North Ottawa Community Hospital, Metropolitan Health Care System or other health care
providers to provide, seek, obtain, or approve any routine, necessary, or emergency health care during the athlete’s involvement in the GVSU 5v5 lacrosse tournament. I understand that this authorization is given in
advance of any specific diagnosis, or treatment or medical care being required and is to serve as specific consent to any and all such diagnosis, treatment or hospital care which may be deemed advisable. I
understand my rights under the Health Insurance Portability and Accountability Act (HIPAA) and authorize GVSU to release information as necessary for managing tournament healthcare. I attest that a physician has
examined the camper in the past twelve months and he/she was found to be in good health. I attest that currently there is no medical reason for the camper not to participate in the strenuous physical activities of
the lacrosse 5v5 tournament. I acknowledge that participation in tournaments and related activities involves assumed and inherent risk of personal injury. I assume such risk on behalf of the participant and give
my permission to the athlete to participate in all tournament activities. I release and agree to hold harmless GVSU, its Board of Trustees, students and employees from all claims, actions, damages and liabilities for
personal injury or damage relating to or arising out of any sports tournament event except where the injury or damage is caused by the gross negligence of the university’s employees. I understand that the
tournament participant will be subject to the rules and regulations of the GVSU WinterWonderLax. I understand that any person who repeatedly disobeys tournament policies or procedures will be immediately
expelled from the tournament. My daughters image may be used by GVSU to advertise future events in either print media or online. GVSU is not responsible for lost or stolen property. Any photographs taken at the
event may be used for publicity and in printed, or online media.
Athlete: ____________________________________________________________________________ Date:__________________________________________
Parent/Guardian Signature: _______________________________________________________________________________________________________________________
Insurance Company: _________________________________________________________________ Policy Number: ____________________________________________
Emergency Contact Name: ____________________________________________________________ Emergency Contact Number: ________________________________
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