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Camps: |
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Player Contact Information: |
First Name: |
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Last Name: |
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Email Address: |
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Cell Phone Nr: |
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Address: |
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City: |
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State: |
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Zip Code: |
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Date of Birth: |
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School: |
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Team/Organization Name: |
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Age: |
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Primary Position: |
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US Lacrosse #: |
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Roommate Request: |
* |
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Guardian Information: |
Primary Guardian Name: |
* |
Father Name: |
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Mother Name: |
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Primary Email Address: |
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Primary Cell Nr: |
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Health Insurance Provider: |
* |
Health Insurance Policy Nr: |
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Payment Method: |
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Please charge $: |
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to my credit card CC#: |
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Exp. Date: |
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MAXIMUM LACROSSE CAMPS insurance coverage is provided through US Lacrosse/Bollinger Insurance Solu)ons. I understand and accept that the risk of injury is possible while playing or prac)cing the sport of lacrosse. I authorize the directors to act for me accordingly to their best judgment in an emergency requiring medical a`en)on. Anyone associated with MAXIMUM LACROSSE CAMPS will not assure campers medical or dental expenses incurred as a result of par)cipa)on in this program. I acknowledge MAXIMUM LACROSSE CAMPS is not responsible for lost or stolen property or money. I also give the camp permission to use, at their discre)on, any camp photos or video taken at the camp in conjunc)on with future publica)on. |
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I ACCEPT |
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Signature of Parent/Guardian: |
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Date: |
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