Mount Si Lacrosse

By signing this form, I acknowledge that I have voluntarily chosen to participate in the Mount Si Lacrosse Club Spring Registration season ("Event"). I understand that lacrosse is a contact sport and involves inherent risks of injury, including but not limited to sprains, fractures, dislocations, and more serious injuries. I hereby assume all risks and responsibilities for any such injury or accident.


Acknowledgement of Risks and Waiver of Liability

I understand the risks involved in participating in this Event and agree to abide by all rules and guidelines imposed by Mount Si Lacrosse Club and its representatives. I hereby release, discharge, and hold harmless Mount Si Lacrosse Club, its agents, representatives, volunteers, sponsors, and other participants from any and all liability, claims, demands, actions, and causes of action arising from or in any way connected with my participation in this Event.


Parental/Guardian Consent (if participant is under 18 years old)

I am the parent or guardian of the registered participant. I have read this release and consent form, and I join in the foregoing waiver and release. I agree that both my child and I are bound by all the terms of this agreement, including the release of liability.

Mount Si Lacrosse Club firmly believes that young athletes learn valuable lessons by watching the behaviors and attitudes of adults and requires all parents to understand and follow our code of conduct:



I will refrain from calling out names of players and cheer for everybody on the team.
I will refrain from sideline-coaching and giving individuals feedback during games and practices.
I will be cautious in providing feedback and do my best to stay positive. I will not ridicule or yell at my child or other participant.
I will leave the officiating to the officials. I am not allowed to make comments, suggestions or communicate in any way with officials and will respect their authority.
I will refrain from confronting opposition supporters.
I will follow the “24 HOUR” rule; If I have a complaint resulting from a game (or practice) situation, I will speak with the coach after the 24-hour cooling-off period and meet with the coach and MSLC Director of Coaching, at a mutually agreed upon time.


I also agree that if I, or any other family member in attendance, fail to abide by the Parent Code
of Conduct rules and guidelines, I will be subject to disciplinary action that could include, but is
not limited to the following:



⦁ Verbal warning by official, head coach, and/or member of the organization
⦁ Written warning
⦁ Parental game suspension with written documentation of incident
⦁ Parental season suspension

MSLC requests your permission to photograph and or videotape your child when she or he participates in Club sponsored practices, games, camps, clinics, and events. In some situations, the Club may identify your child by name and age.

Photographing and videotaping players will be limited to:


Documenting games for educational/coaching purposes.
Providing visual content for our web page.
Providing team pictures/individual athlete pictures to news outlets.
Creating local educational and promotional information.
Photos or video content will never be sold for commercial profit.
Your child may appear on videotape or in photographs even though she or he may not be the subject of the photo or videotape.
I /We the parents or legal guardian of the player applicant have read the MSLC Photo/Video Release.

Please check the appropriate box below

DO give permission to you to include my child’s image on photographs or videotape taken while my child is participating in Mount Si Lacrosse Club sanctioned activities.
DO NOT give permission to videotape or photograph my child.

What is sudden cardiac arrest? Sudden Cardiac Arrest (SCA) is the sudden onset of an abnormal and lethal heart rhythm, causing the heart to stop beating and the individual to collapse. SCA is the leading cause of death in the U.S. afflicting over 300,000 individuals per year. SCA is also the leading cause of sudden death in young athletes during sports.

What causes sudden cardiac arrest?
SCA in young athletes is usually caused by a structural or electrical disorder of the heart. Many of these conditions are inherited (genetic) and can develop as an adolescent or young adult. SCA is more likely during exercise or physical activity, placing student-athletes with undiagnosed heart conditions at greater risk. SCA also can occur from a direct blow to the chest by a firm projectile (baseball, softball, lacrosse ball, or hockey puck) or by chest contact from another player (called “commotio cordis”).

While a heart condition may have no warning signs, some young athletes may have symptoms but neglect to tell an adult. If any of the following symptoms are present, a cardiac evaluation by a physician is recommended:
Passing out during exercise
· Chest pain with exercise
· Excessive shortness of breath with exercise
· Palpitations heart racing for no reason)
· Unexplained seizures
· A family member with early onset heart disease or sudden death from a heart condition before the age of 40 .

How to prevent and treat sudden cardiac arrest?
Some heart conditions at risk for SCA can be detected by a thorough heart screening evaluation. However, all schools and teams should be prepared to respond to a cardiac emergency. Young athletes who suffer SCA are collapsed and unresponsive and may appear to have brief seizure-like activity or abnormal breathing (gasping). SCA can be effectively treated by immediate recognition, prompt CPR, and quick access to a defibrillator (AED). AEDs are safe, portable devices that read and analyze the heart rhythm and provide an electric shock (if necessary) to restore a normal heart rhythm. Remember, to save a life: recognize SCA, call 9-1-1, begin CPR, and use an AED as soon as possible.

Student/Parent Concussion and Sudden Cardiac Arrest Awareness Form:
Mount Si Lacrosse Club believes participation in athletics improves physical fitness, coordination, self-discipline, and gives students valuable opportunities to learn important social and life skills. With this in mind it is important that we do as much as possible to create and maintain an enjoyable and safe environment. As a parent/guardian or student you play a vital role in protecting participants and helping them get the best from sport. Player and parental education in this area is crucial which is the reason for the Concussion Management and Sudden Cardiac Arrest Awareness pamphlet you received. Refer to it regularly. It can be found at www.mountsilacrosse.org under forms and documents. This form must be signed annually by the parent/guardian and student prior to participation in Mount Si Lacrosse Club.

If you have questions regarding any of the information provided in the pamphlet, please contact the Board of Directors.

Please review the attached Concussion Awareness Info Sheets on concussion awareness.