Medical Form – Battle of Nashville

Lacrosse Medical Form/Release and Insurance Information
Note: Please print legibly in INK or type. This form must be completed in FULL, including signatures of participant and parent or legal guardian if
under the age of 18 years old. Players will NOT BE ALLOWED to participate without the completed medical and parental release/insurance form.
Player ____________________________________________________________
Name of Tournament BATTLE OF NASHVILLE LACROSSE TOURNAMENT
Date of Birth_____________________
Date(s) of Tournament October 3, 2015
Medical History
Are you ALLERGIC to any of the following? Medications – Insect bites – Foods – Other
YES
If YES, indicate what___________________________________________________________________
NO
Are you presently taking, or will be taking any medication during the tournament?
YES
If YES, indicate what____________________________________________________________________
NO
Are you being treated for an injury or illness at this time?
YES
If YES, indicate what____________________________________________________________________
NO
Circle all of the following Immunizations that ARE up to date:
MMR
Diptheria
Tetanus
Polio
Pertussis-Whooping Cough
Do you have/had any of the following? Circle all that apply: Rubella Measles Mumps ChickenPox Pneumonia
Epilepsy
Heart Condition
Other___________________________________________________
Diabetes
NOTE: If you have a history of serious illness and/or injury (i.e. heart murmur, surgery, epilepsy, etc.) a note from a licensed physician must
accompany this form to insure that the individual may be cleared to participate in the tournament.
I certify that I am physically fit and able to participate fully in the above indicated Lacrosse Tournament.
Signature of Participant___________________________________________________ Date__________________________
Signature of Parent/Guardian_______________________________________________ Date__________________________
(If under the age of 18 years old)
Release & Insurance Information
I am willfully attending and participating in the BATTLE OF NASHVILLE LACROSSE TOURNAMENT. Furthermore, I hereby grant permission
to the tournament staff to render preventative, first aid and/or emergency treatment that they deem necessary to my health and well-being. In the
event of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made by the tournament staff
to notify the designated emergency contacts in the most expeditious manner possible. If said staff is unable to communicate with emergency contact,
the treatment deemed necessary for my health and well-being may be given.
I hereby:
1. Certify, that to the best of my knowledge, the medical information requested is complete and correct.
2. Agree to assume all risk of personal injury arising from participation in the above indicated tournament, and understand that the sport
indicated above involve the potential for injury.
3. Agree not to hold the staff responsible for any injury sustained during participation at tournament.
4. Agree not to bring suit against the Lacrosse Tournament, Rise Lacrosse and/or its staff for any injury sustained.
5. Understand that if necessary, in the judgment of the Tournament staff, to use outside medical, surgical, or dental treatment for the health
and well-being, that all such expenses shall be the responsibility of the participant and/or parent/guardian.
6. Agree to accept any decisions made by the Tournament Director in the termination of tournament attendance due unacceptable behavior.
PLEASE BE ADVISED THAT IT IS IMPERATIVE THAT YOU ARE IN GOOD HEALTH WHEN ARRIVING AT THE TOURNAMENT. THE
DUTIES OF TOURNAMENT STAFF PERSONNEL CANNOT INCLUDE PROVIDING MEDICAL CARE FOR PARTICIPANTS ARRIVING
AT THE TOURNAMENT WITH PRE-EXISTING CONDITIONS.
INSURANCE INFORMATION
Insurance Company NAME, ADDRESS & TELEPHONE ____________________________________________________________
___________________________________________________________________________________________________________
Policy Holder’s Name________________________________________ Policy Number___________________________________
Group Number______________________________________________
Emergency Contact (You must provide a number or someone that can be reached during tournament hours, whether it is the parent or a designated
emergency contact):
Name_________________________________________ Relationship_________________________ Players US Lacrosse #________________
Home Number____________________ Work Number_____________________ Cell Number________________________________
Signature of Participant___________________________________________________ Date__________________________
Signature of Parent/Guardian_______________________________________________ Date__________________________
(If under the age of 18 years old)