Champion Lacrosse    Southgate Parks and Recreation Registration Form

Complete this entire form.  Please print clearly.

Student Name_____________________________________ Student Email ______________________________

Parent Email 1 ______________________________      Parent Email 2 _________________________________

Address ____________________________________    City _____________________________  Zip________  

Phone (_____) ______________  Birth Date _____/_____/_____  

Year of High School Graduation _________    Grade ________
(Academic Year 2004-05: 12=2005, 11=2006, 10=2007, 9=2008, 8=2009, 7=2010, 6=2011, 5=2012, 4=2013, 3=2014, 3=2015, 1=2016, K=2017)

School ________________________________________  

Please select a t-shirt size.

T-Shirt Size:										
	
___Youth Small			   			
___Youth Medium					
___Youth Large			  			  
___Adult Small						
___Adult Medium
___Adult Large

Payment:  Please make checks payable to “Champion Lacrosse.”
		Lacrosse Camp, stick and t-shirt………………	$175

Please check our web site for updates: www.championlacrosse.com. Please call us with your questions at (248) 255-1287.  You can also link to our online registration at championlacrosse.com

Your completed form and check payable to "Champion Lacrosse" are accepted on a first-come, first-served basis.   

Mail this form to:
Champion Lacrosse 
30800 Telegraph Road					
Suite 3833                                                                      
Bingham Farms, MI 48025.

Alternative Registration Location:
Recreation Office at City Hall
14400 Dix-Toledo Road 
8-5 Mon.-Fri.
(734) 258-3035 or 3031

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT (“AGREEMENT”)
 
Effective today:________________
In consideration of my use of services provided by Champion Lacrosse, I represent that I understand the nature of this Activity and that I am qualified, in good health, and in proper physical condition to participate in such Activity.  I acknowledge that if I believe event conditions are unsafe, I will immediately discontinue participation in the Activity.
 
I fully understand that this Activity involves risks of serious bodily injury, including permanent disability, paralysis, and death, which my be caused by my own actions, or inaction, those of other participants in the event, the conditions in which the event takes place, or the negligence of the “releasees” named below; and that there may be other risks either responsibility for losses, costs, and damages I incur as a result of my participation in the Activity.
 
I hereby release, discharge and covenant not to sue CITY OF SOUTHGATE,  and it’s personnel, its elected officials, officers, employees, and SOUTHGATE PARKS & RECREATION DEPT, their officers, instructors, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers and, if applicable, owners and lessors of premises, CHAMPION LACROSSE, PREMIER SPORTS GROUP, INC., its respective administrators, directors, agents, officers, volunteers, umpires, referees and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the Activity takes place, (each considered on of the “RELEASEES” herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the “releasees” or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save and hold harmless each of the releasees from any loss, liability, damage, or cost which any may incur as the result of such claim.
 
I have read the RELEASE AND WAIVER OR LIABILITY, ASSUMPTION OF RISK, AND INDEMINTY AGREEMENT, understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extend allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in the full force and effect. This agreement is effective at all times subsequent to the date of it’s execution unless rescinded by an express writing sent to the above by certified mail.
 
PARENTAL CONSENT
AND I, the minor’s parent and/or legal guardian, understand the nature of the above referenced activities and the minor’s experience and capabilities and believe the minor to be qualified to participate in such activity.  I hereby release, discharge, covenant not to sue and AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS each of the Releasees from all liability, claims, demands, losses, or damages on the minor’s account caused or alleged to have been caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations, and further agree that if, despite this release, I, the minor or anyone on the minor’s behalf makes a claim against any of the above Releasees, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS each of the releasees from any litigation expenses, attorney fees, loss liability, damage, or cost any Releasee may incur as the result of any such claim.

_____________________________________________                      _________________.
Parent/Guardian Signature								Date