Breakout Lacrosse  Tournament Registration

Register Today Breakout Flare

Please make checks payable to "Bison Brawl" and mail to:
     Joe Conner
     Men's Lacrosse     
     KLARC - Moore Ave.
     Bucknell University
     Lewisburg, PA 17837

Team Name *
Coach/Player *
Division *
Number
First Name *
Last Name *
Graduation Year
Position:
Email *
Street *
City *
State *
Zip *
Phone Number 1 *
Phone Number 2
GPA
SAT/PSAT
1st College Choice
2nd College Choice
3rd College Choice
Housing Option
Roomate Request
Insurance Carrier *
Policy Number *
I have read and understand the following statement: *
 Yes
 No
 

Waiver

I authorize the Bucknell Bison Brawl and its medical staff to use their best judgment in allowing my child to receive emergency medical or surgical treatment if necessary.  I understand that every effort will be made to contact me prior to such action  (It is imperative that your child be in good health when arriving to the event.  The duties of the Breakout Lacrosse Bison Brawl staff can not include providing medical care for players arriving at the event with a pre-existing medical condition.

I hereby :
1.  certify to the best of my knowledge, the medical information is complete and correct and has been provided voluntarily.
2.  agree to assume all risk of personal injury arising from participation in the Breakout Lacrosse Bison Brawl, understanding that this sport does involve potential for serious injury, disability and death. 
3.  agree not to hold the Breakout Lacrosse Bison Brawl or any of the coaching staff responsible for any injury sustained during the practices, games or any events associated with the camp.
4.  agree not to bring suit against Breakout Lacrosse Bison Brawl, or its staff for any injury sustained during the event.
5.  agree to allow Breakout Lacrosse Bison Brawl staff, coaches and medical staff to use sound judgment in obtaining necessary medical care, at the expense of the parent/guardian.
6.  agree to accept any decisions made by the Breakout Lacrosse Bison Brawl staff, coaches and/or medical staff in terminating attendance at the event due to unacceptable behavior on or off the field.