Teens Name
Address
City, State, Zip
Teen’s Phone
Number
Teen’s Email
Parent/Guardian
Name and
Number
I, the Participant/parent/guardian, in registering at the La Crosse Wellness Center and Fieldhouse, understand that in
attending the registered program and using the facilities, do so at my own risk. La Crosse Wellness Center and Fieldhouse,
and its owners, employees and agents, shall not be liable for any damages whatsoever arising from any personal injury or
property loss sustained by the participant and my family in or about any programs on the premises. I acknowledge and am
aware of the risks inherent in participating in the registered program (both practice and competitions); that indoor sport
programs are physical which can require considerable running, starting, stopping and physical exertion; and could potentially
lead to limb injuries; possible permanent disability and death. Participants assume full responsibility for all injuries and
damages which may occur in or about any programs on the premises and I do hereby fully and forever release, discharge, and
hold harmless the La Crosse Wellness Center and Fieldhouse, all associated facilities and its owners, employees and agents
from any and all demands, damages, rights of action, present or future resulting from or arising out of any person’s
participation in any programs or use of its facilities. I agree to follow the rules of play and conduct set by the La Crosse
Wellness Center and Fieldhouse. I understand that failure to do so may result in suspension from participation. Also, I waive
all rights to any photos taken for use in any La Crosse Wellness Center and Fieldhouse publications
*A PARENT’S SIGNATURE IS NEEDED IF THE INDIVIDUAL PLAYING IS UNDER 18 (Childs name/parents signature)
Participant Name:_______________________________________ Signature: ________________________________
Parent Signature:______________________________________E-Mail:_____________________________________
Emergency Contact:____________________________________ Emergency Phone #: ________________________
Office Use Only
Located at 2839 Darling Ct. La Crosse
608.781.7627 or
[email protected]
Parent add on ($59): ____________________ Teen payment: $59
Total: _________________________________________________
CC: __________________________________ Exp:___________
Cash: __________ Check #: _____________