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Janesville Lacrosse Club Boys High School Lacrosse

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					                             Janesville Lacrosse Club
                            Boy’s High School Lacrosse
                                Registration Form
                             2007 SPRING SEASON
TEAM CONTACTS
Parent Contact: John Haney, 608-758-1791
CLUB MEMBERSHIP FEE $ 100.00 - Checks payable to: Janesville Lacrosse Club.
There is an optional $25 fee if you would like to contribute towards coaching.
Club membership fees and a completed registration form are due by March 5, 2007.
Club Membership Fees coves the cost of league fees, coaches, referees, team equipment,
and uniforms (required US Lacrosse membership not included).
After March 5th, 2007, Registration may continue if there are spots available on the team.

PLAYER
Name____________________________________________
Address_________________________City____________________Zip___________
Age ______Date of Birth________ School__________________ Grade________
Phone_________________ Email*_________________________________
US Lacrosse membership # (required) _______________________ expiration date________
Previous experience_______________________________________ Position____________

PARENTS

Father____________________________ Mother___________________________
Home Phone_____________________________ Home Phone________________________
Work Phone______________________________ Work Phone________________________
Cell Phone______________________________ Cell Phone__________________________
E-mail*_________________________________E-mail*_____________________________
*Most information and announcements are via e-mail. The players e-mail address will be
used as the primary address for correspondence unless otherwise indicated.

EMERGENCY CONTACT
Name _____________________________Relationship______________________

Home Phone______________ Office Phone _____________ Cell Phone_____________

I give consent for my child ______________________________________ to participate in
any Janesville Lacrosse Club sponsored programs. I certify that my child’s membership to
US Lacrosse (www.uslacrosse.org) is current and valid. I realize that lacrosse is a physical
sport played with a hard rubber ball, sticks, and protective equipment. I release the Janesville
Lacrosse Club and its members, and all coaching staff from any and all liability that may
occur as a result of participation during play or observation of lacrosse.

Signature of Parent/Guardian_______________________________ Date___________
Player Signature________________________________________ Date________________
PHYSICIAN INFORMATION
Name_______________________________________Phone_____________________
Address_________________________ City____________________ Zip___________
Insurance Information_____________________________________________________
Player Allergies or Known Disabilities________________________________________
Other Important Medical Information_________________________________________

MEDICAL AUTHORIZATION
I/We hereby give permission for any and all medical attention necessary to be
administered to my child, (full name)__________________________in the event of
accident, injury, sickness or until such time that I/We can be contacted.

I/We the parent/guardian undersigned herby certify that I/we are the parent or legal
guardian of the participant and hereby give permission to Janesville Lacrosse Club to
seek appropriate medical attention, as they deem necessary to insure the well being of my
child. I/We also assume the responsibility for the payment of any such medical treatment,
including but not limited to transportation required for treatment.

Signature of Parent/Guardian_______________________________ Date_____________

WAIVER AND RELEASE
I (we), the undersigned parent(s) or guardian(s) of the player, hereby apply to the
Janesville Lacrosse Club for permission for our child to participate in the 2007 spring
lacrosse program. As a condition of our child playing, we agree that our child’s
participation will be subject to the following representations and rules:
1. Our child has had a recent physical, and we represent that he is mentally and physically
fit to play lacrosse.
2. We assume responsibility for our child’s transportation to and from practice.
3. We acknowledge that lacrosse is a physical sport, and assume all risks and hazards
incidental in playing the sport. We hereby release, indemnify and hold harmless
Janesville Lacrosse Club, its organizers, officers, coaches and staff from any claim and
liability arising out of participation.
4. We acknowledge that this form has been signed by both or applicable parents and/or
guardians. If signed by one parent or guardian, we signify that they alone have legal
custody and responsibility for the player.

Signature of Parent/Guardian___________________________________ Date_________

FEE ACKNOWLEDGEMENT
The Janesville Lacrosse Club is not school sponsored and receives no tax dollars or any
funds from the Janesville school system, the player’s fees must cover any and all
expenses incurred by the Janesville Lacrosse Club. However, the Janesville Lacrosse
Club will look for opportunities to raise money through fundraising. By participating in
these fundraising activities it is possible to lower the estimated player costs, and also
raise some of the funds required to pay your individual fees.
Membership fees will cover the following expenses: game referees, goals, balls, field
expenses, field equipment, coaches’ expenses, league dues, WLF dues and uniforms
(player will keep their uniform).
Further anticipated costs that will be the responsibility of each player may include, but
may not be limited to, all personal equipment required to play lacrosse, transportation to
and from all practices and some games, optional team equipment bags, warm-ups, and
spirit wear clothing, tournament entry fees, and hotel and transportation costs for any
possible overnight trips and/or the State Tournament.

Expenses for the 2007 season have been estimated. If any unforeseen expenses are
incurred, fundraising efforts will be made to cover them before assessing an extra fee to
each player. However, if you choose not to participate in these efforts, you may be
assessed your portion of the expenses.

If a player withdraws from the team prior to March 26, 2007 they will be reimbursed the
Club Membership Fees, less $25 (try-out field expenses).
For a withdrawal after March 26, 2007 the following guidelines will apply:
If a player quits the team by his own choosing or is removed for disciplinary or other
reasons, they will not qualify for any reimbursements.
If a player has incurred a “season-ending” injury or illness, as determined by a physician,
they will be reimbursed the prorated fees for the number of weeks missed based on the
length of lacrosse season, less the cost of the uniforms.

We understand and acknowledge our responsibility and agree to pay the fees as
determined by the Janesville Lacrosse Club to the Janesville Lacrosse Club.

Signature of Parent/Guardian___________________________________ Date_________


UNIFORM NUMBER
Numbers will be assigned on a first come first serve basis.

1st Choice_______, 2nd Choice________, 3rd Choice_________


VOLUNTEERS (we welcome your participation)
____Coaching ____Parent Board Member ____Referee ____ Field Set-up
____Fund raising ____Promotions/Marketing ____Scorekeeper____ Youth Lacrosse




                               Mail forms and fees to:

                              Janesville Lacrosse Club
                               6649 N. Lazy River Rd.
                                Janesville, WI 53545

				
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