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MILL VALLEY LACROSSE ASSOCIATION YOUTH REGISTRATION (through 8th Grade) 2013 PLAYER Player Name: Date of birth:

Age:

Shorts Size:

Address:

Jersey Size:

City:

State:

ZIP Code:

School:

Grade:

Years Played:

All players are required to be a member of US Lacrosse. Membership #:

PARENT/GUARDIAN Parent/Guardian:

Home:

Email:

Cell:

Parent/Guardian:

Home:

Email:

Cell:

INSURANCE INFORMATION Insurance Carrier: Policy Number:

FEES – PLEASE CHOOSE ONE

Registration Fee - $295.00

Discount on 11/19/12 Only - $265

3 Payment Option - $99/Month

Nov 19

Dec 15

Jan 15

ALL FEES DUE BY JANUARY 15, 2013 MAKE CHECKS PAYABLE TO MVLA MVLA Use Only: Amount:

Date:

Check/Cash:

Amount:

Date:

Check/Cash:

Amount:

Date:

Check/Cash:

SIGNATURE We acknowledge and understand that the student will be engaging in activities that involve risk of serious injury, including permanent disability or death. We freely and knowingly assume all of the risks of injury that might occur during the player’s participation in the Mill Valley Lacrosse Association and we accept personal responsibility for any and all damages following any such injury. In consideration of being allowed to participate in the MLVA, we agree to release and hold MVLA, its coaches, members, and volunteers harmless and indemnified from and against any and all claims, lawsuits, or causes of action arising from or out of any injury that the student may suffer while participating in MVLA activities. We understand that the Mill Valley Lacrosse Association is an independent club run by and for its members and is not managed or supervised by Mill Valley High School or DeSoto Schools. Parent/Guardian:

Date: Mail completed form and payment to: MVLA, PO Box 861073, Shawnee, KS 66286

REGISTRATION IS NOT FINAL UNTIL ALL FEES ARE RECEIVED. FEES DUE – JANUARY 15, 2013 ($35 LATE FEE AFTER 1/15/13)


Youth Registration Form - 2013