2019-2020 Registration

Recognizing Validity of Electronic Signature
Pursuant to the Texas Uniform Electronic Transmissions Act, an electronic signature has the same legal effect as a manual or handwritten signature. An electronic signature will not be denied legal effect or enforceability solely because it is electronic, and any requirement for a signature is satisfied by an electronic signature. By submitting an electronic signature, the individual identified and providing the electronic signature herein verifies acknowledgement of the binding legal effect and enforceability of the electronic signature. By clicking the box beside "I agree", you agree that this is valid as your signature. You hereby swear that you are the parent or legal guardian of the student registering for the Austin Youth Lacrosse Program ("Program") and that the information is accurate to the best of your knowledge. *

Parent/Guardian Agree
Parent/Guardian Signature *

Clear
Parent/Guardian Printed Name *

First Name Last Name

PARENTAL or GUARDIAN CONSENT, EMERGENCY MEDICAL INFORMATION, and EMERGENCY MEDICAL RELEASE
APPROVAL TO PARTICIPATE

I do hereby give approval for my daughter or guardianship to participate with the Program.

HOLD HARMLESS

I do hereby, for myself, my heirs, executors, administrators, waive, release, absolve, indemnify and agree to hold harmless, any and all adults who coach or assist in coaching, Austin Youth Lacrosse (AYL) and the AYL Girls' Youth Program, the AHS Girls Lacrosse Program and its members, officers, board members, other participants, AHS Girls Lacrosse Team players, Austin High School, the Austin Independent School District, the West Austin Youth Association, AHS Boys Lacrosse Program and its members, officers, board members, other participants, and any of the above named parties’ representatives, successors, supervisors, sponsors, or organizers, for any claims, actions or injuries in connection with the outings, events, practices or games related to the Program.

TRANSPORTATION

I likewise release from liability any person(s), airline, bus company or other transportation service transporting any player, in a privately owned or leased vehicle, to and from any activities connected with the Program.

Important: The Program does not provide player transportation to or from any activities. The only transportion that is contemplated is the unexpected variety, such as a parent's unanticipated inability to retrieve a child from a Program activity or if a child requires transportation in a medical situation.

REMOVAL FROM TEAM ACTIVITIES

Furthermore, I agree that if the above named child or parent/guardian’s behavior is inappropriate, unsafe, or detrimental to the group, I will be contacted immediately to secure a means of removing my child or parent/guardian from the practice, game, event, or activity's premises. I understand that any financial costs incurred as a result of my child or parent/guardian being sent home, are my responsibility.

_________________________

MEDICAL INFORMATION and EMERGENCY CARE

MEDICAL INFORMATION. I understand and agree that, in order to provide a coordinated system of care, the coaching staff may exchange health care information about a player with his or her physician or other healthcare providers. I consent to allow Program personnel to contact the player's physician directly to share information or request records pertinent to athletic participation. I give permission to release and share all necessary health information. I understand that this information will automatically be shared in emergency situations as necessary.

EMERGENCY CARE. I also give permission to Program staff to seek any emergency care should the child be involved in any accident or be injured in any practices, games, events, or activities. I understand that in any such instance, all attempts will be made to contact parents, guardians, or others listed under Emergency Contacts. In the event I cannot be contacted, I hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for my child as is deemed medically necessary.
Parent/Guardian Signature *

Clear
Parent/Guardian Printed Name *

First Name Last Name
Physician Name *

First Name Last Name
Physician Phone Number *

Area Code Phone Number
Medical Insurance Provider *
Policy Holder's Name *
Policy Number *
Medication taken regularly. *
If none, write that in the box because, you know, the asterisk.
Medical Information: Please list any information that may be pertinent in an emergency. (Allergies, Asthma, Medications, etc.) *
If none, write that in the box because, you know, the asterisk.
Special conditions that should be known by athletic trainer or physician. *
If none, write that in the box.
Any other information not covered above that you would like to note about this player's medical wellbeing (hospital preference, faith-related awareness, etc.).
Person #1 to Notify in Event of an Emergency *

First Name Last Name
Person #1's Relationship to Player *
Person #1's Mobile Phone Number *

Area Code Phone Number
Person #2 to Notify in Event of an Emergency

First Name Last Name
Person #2's Relationship to Player
Person #2's Mobile Phone Number

Area Code Phone Number
Person #3 to Notify in Event of an Emergency

First Name Last Name
Person #3's Relationship to Player
Person #3's Mobile Phone Number

Area Code Phone Number

PARENTAL WAIVER - COVID / INFECTIOUS DISEASE
Parent Signature *

Clear
Parent Printed Name *

First Name Last Name
Date *

Month Day Year
Date

PARENTAL CONSENT FORM - WEB PAGE, SOCIAL MEDIA, AND PROMOTIONAL MATERIALS
Please Select One *

I do hereby give permission for the Program to use my daughter's and parent/guardian's name and/or photo on the Program, CAPLAX, and/or Austin High School Girls Lacrosse's web page, social media platforms, and official team materials. I DO NOT give permission for the Program to use my daughter's and parent/guardian's name and/or photo on the Program, CAPLAX, and/or Austin High School Girls Lacrosse's web page, social media platforms, and official team materials.
If permission is NOT granted, I futher understand that if any team photo or group photo is used, her face will be blurred out and her name will not be listed.

2022 PROGRAM DUES AND OPTIONAL DONATION
REGISTRATION COSTS

Player registration costs for 2021 are:

SCOOPERS (First and Second graders) $125

LIGHTNING (Third and Fourth graders) $225

OPTIONAL PROGRAM DONATION

As stated above, we appreciate your consideration of an optional tax-deductible program donation, but there is no requirement or expectation that you participate.

The optional donation part of the order form is set up in increments of $10.00 donations. (e.g., If you would like to donate $30, enter "3" as the quantity. If you want to donate $40, enter "4" as the quantity, etc.)

Annual Dues *

SCOOPERS (First & Second Grades) $ 125.00

LIGHTNING (Third & Fourth Grades) $ 225.00

Optional Tax-Deductible Program Donation $ 10.00

Quantity of $10.00 Donations (ex: to donate $50 enter 5 as the quantity)

Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

THANK YOU!
When you are all finished, please click the "Submit" button below.

See you soon!

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The Parent or Guardian Filling Out This Form Is...

Player Information

Parent/Guardian Information

Recognizing Validity of Electronic Signature

PARENTAL or GUARDIAN CONSENT, EMERGENCY MEDICAL INFORMATION, and EMERGENCY MEDICAL RELEASE

PARENTAL WAIVER - COVID / INFECTIOUS DISEASE

PARENTAL CONSENT FORM - WEB PAGE, SOCIAL MEDIA, AND PROMOTIONAL MATERIALS

2022 PROGRAM DUES AND OPTIONAL DONATION

THANK YOU!