First Name *
Last Name *
Graduation Year *
Male
Female
Gender*
Attack
Midfield
Face-off
LSM
Defense
Goalkeeper
Position
*
High / Middle School / Youth Program / College Program*
2011 Playing Level *
(Choose)
Middle School
Youth Program
High School JV
High School Varsity
College Varsity
College Club
Years Playing*
Age as of Jan. 1, 2012 *
Date of Birth (MM/DD/YYYY) *
Your email address
*
Home phone number
*
Cell phone number
*
(yours or parents)
Address
*
City
*
State
*
Zip Code
*
Emergency Contact
*
Emergency phone number
*
Name of Insured
*
Insurance Provider
*
Insurance Policy Number
*
Program Selection*
Lacrosse Champion Package
Speed, Agility & Conditioning
Lacrosse Skills Camp
Goalkeeper Camp
Shooter & Dodging Camp
Youth Camp
Youth Indoor League (7/8)
Youth Indoor Indoor (5/6 grade)
High School League (V)
High School League (JV)
Men's Indoor League
Additional Information you would like to give:
2012 Winter Indoor / 2012 Summer Silverbacks
Do you plan on participating in Silverbacks
High School or Youth Travel Team Tryouts
for Summer 2012 season?
NO
YES
LIABILITY RELEASE & WAIVER
Please read the following Liability Release and Waiver and place a check mark if you agree to the terms then click SUBMIT to send the form.
RELEASE & WAIVER This must be read and acknowledged at bottom of form IN CONSIDERATION of being permitted to participate in any way in SILVERBACKS LACROSSE TEAM AND Z CAMPS, LLC including but not limited to, any tournaments, leagues, camps, skill sessions, and/or practices ("Activity") I, for myself for personal representatives, assigns, heirs, and next of kin: (i) ACKNOWLEDGE, agree, and represent that I understand the nature of the Activity and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity. (ii) FULLY UNDERSTAND THAT: (a) THE ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS AND DANGERS"); (b) these Risks and Dangers may be caused by my own or my minor’s actions or inactions, the actions or inaction's of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of the minor in the Activity. (iii) HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE SILVERBACKS LACROSSE TEAM, Z CAMPS, LLC, CHRISTIAN ZWICKERT, his or their respective administrators, coaches, directors, agents, sub-agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owner and lessors of premises on which the Activity takes place, (each considered one 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 AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 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 litigation expenses, attorney fees, loss, liability, damage, or cost which may incur as the result of such claim. I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT. MINOR RELEASE AND I, THE MINOR'S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF THE ACTIVITY AND THE MINOR'S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION 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 RELEASEE'S FROM ALL LIABILILTY CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR'S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATION 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 RELEASEES NAMED ABOVE, I WILL INDEMNITY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM. Authorization to Use of Photographs and Images. I do hereby grant permission to Silverbacks Lacrosse Team, Christian Zwickert and Z CAMPS, LLC, its owner(s), officer(s), trustee(s), employee(s), agent(s), sub-agent(s), representative(s), successor(s), licensee(s) and assign(s) to photograph the image of the registered player herein, likeness or depiction. I hereby grant permission to Silverbacks Lacrosse Team, Christian Zwickert and Z CAMPS, LLC to edit, crop, or retouch such photographs, and waive my rights to inspect the final photographs. I hereby consent to and permit photographs of the registered player herein and or those of my minor children to be used by Silverbacks Lacrosse Team, Christian Zwickert and Z CAMPS, LLC worldwide for any purpose, including educational and advertisement purposes, and in any medium, including print and electronic. I understand that Silverbacks Lacrosse Team, Christian Zwickert and Z CAMPS, LLC may use such photographs without associating any names thereto. I further waive any claim for compensation of any kind for Silverbacks Lacrosse Team, Christian Zwickert and Z CAMPS, LLC use or publication of photographs of me, the registered player or those of my minor children. I hereby fully and forever discharge and release Silverbacks Lacrosse Team, Christian Zwickert and Z CAMPS, LLC from any claim for damages of any kind (including, but not limited to, invasion of privacy; defamation; false light or misappropriation of name, likeness, or image arising out of the use or publication of photographs of me, the registered player herein or those of my minor children by Silverbacks Lacrosse Team, Christian Zwickert and Z CAMPS, LLC, and covenant and covenant and agree not to sue or otherwise initiate legal proceedings against Silverbacks Lacrosse Team, Christian Zwickert and Z CAMPS, LLC for such use or publication on my own behalf or behalf of the registered players herein or on behalf of my minor children. All grants of permission and consent, and all covenants, agreements and understandings contained herein are irrevocable.
I have read and accept the terms of the Release and Waiver of Liability,
Assumption of Risk, Indemnity and Parental Consent, and Use of
Photographs and Images AGREEMENT
(ABOVE)
Yes
No
2012 REGISTRATION FORM