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Lax Camp Online Registration
Lacrosse Registration
INSTRUCTIONS:
Please fill out the registration form below, by submitting the registration form you will have agreed to the waiver for the camp. Please read the liability waiver before submitting the registration form.
***PLAYER INFORMATION
Player Name
*
First
Last
Age
*
Please enter a value between
6
and
14
.
Ages 6 - 14
School
*
Grade in Fall of 2012
*
Please enter a value between
1
and
12
.
Years of Experience
*
0
1
2
3
4
5
6
7
8+
Shirt Size
*
Small
Medium
Large
X- Large
Any issues we should be aware of?
Insurance Provider
Insurance Policy Number
***PARENT INFORMATION
Parent / Guardian Name
*
First
Last
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Enter Email
Confirm Email
Home Phone
*
(###)### - ####
Cell Phone
(###)### - ####
Emergency Contact Name
*
First
Last
Emergency Contact Number
*
(###)### - ####
***AGREEMENT
BY CLICKING SUBMIT WE THE UNDERSIGNED PARENT OR GUARDIAN OF THE ABOVE PLAYER, A MINOR, DO HEREBY AUTHORIZE THE DIRECTORS OF THE iMATTER LACROSSE CAMP OR THEIR DEIGNEE, TO SELECT HOSPITAL FACILITIES AND / OR A PHYSICIAN OF THEIR CHOICE AND AUTHORIZE TREATMENT OF THE ABOVE NAMED CAMPER ON AN EMERGENCY BASIS IN THE EVENT THAT TREATMENT BECOMES NECESSARY DURING THIS SPORTS CAMP. WE HEREBY GRANT PERMISSION TO PARTICIPATE IN THE CAMP PROGRAM AND ACKNOWLEDGE THAT THE CAMPER NAMED PHYSICALLY FIT TO PARTICIPATE IN ALL CAMP ACTIVITIES. THE ATHELETE WILL OBEY ALL FACILITY RULES AND REGULATIONS OR IS SUBJECT TO DISMISSAL FROM THE CAMP AND WILL BE SENT HOME IMMEDIATELY. BY SUBMITTING THIS FORM, I AM ACKNOWLEDGING MY WILLINGNESS TO ENROLL MY CHILD INTO THE iMATTER LACROSSE CAMP UNDER THE CIRCUMSTANCES STATED ABOVE. THE SUBMISSION OF THIS FORM RELIEVES ALL CAMP DIRECTORS AND FACILITIES, AND DELEGATED REPRESENTATIVES FROM ANY FINANCIAL RESPONSIBILITY.
Registration Fee
*
Price:
$50.00
Total
$0.00
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