PERMISSION TO AUTHORIZE MEDICAL CARE

I GIVE AUTHORITY TO THE THOUSAND OAKS LACROSSE (“TOL”), ITS COACHES, ASSISTANT COACHES AND FIELD VOLUNTEERS TO OBTAIN APPROPRIATE EMERGENCY MEDICAL ATTENTION FOR MY PLAYER IN THE EVENT PLAYER IS INJURED WHILE PARTICIPATING IN THE SPORT OF LACROSSE, IN THE EVENT THAT I AM OR ANOTHER PARENT OR GUARDIAN CANNOT READILY BE CONTACTED TO GRANT SUCH PERMISSION.

I CERTIFY THAT PLAYER HAS UNDERGONE A PHYSICAL EXAMINATION WITHIN THE PAST YEAR AND HAS THE PHYSICIAN’S AND MY PERMISSION TO PLAY A CONTACT SPORT. I ALSO CERTIFY THAT PLAYER IS COVERED UNDER THE GIVEN PRIMARY POLICY AND UNDERSTAND THAT THE INSURANCE PROVIDED TO TEAM MEMBERS, INCLUDING PLAYER, IS IN IS LIMITED AND ONLY APPLIED IN EXCESS OF PLAYER’S PRIMARY POLICY. I AGREE TO NOTIFY THE COACH IMMEDIATELY IF THE PRIMARY POLICY DESCRIBED ABOVE IS NOT VALID FOR ANY REASON.

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