‘08 GRANITE STATE LACROSSE CAMP REGISTRATION

 

Instructions: Please print & complete this Form/Waiver and mail with $100 deposit or payment in

full to address below. Space is limited in both sessions.

Please make checks payable to:  American Lacrosse Company

Mailing Address:  American Lacrosse Company,  P.O. Box 10142,  Bedford, NH  03110

 

Name (please print) _____________________________________ Age/Grade________

 

Street Address_______________________________________School_______________

 

City_________________________________ State_____________ Zip Code _________

 

Home Phone____________________________ Cell Phone________________________

 

Email (required)__________________________________________________________

 

Position:   _______Attack _______Midfield_______Defense _______Goalie

 

Registering for Session(s):

_______ $295 Session 1 (June 30-July 3, 9am-4pm @ The Derryfield School, Manchester)

_______ $195 Session 2 (July 14-July 18, 9am –12:30 pm @ Joppa Hill Field, Bedford)

 

PARTICIPANT WAIVER STATEMENTS

 

Player Name:_______________________________________________________________

I, the undersigned, hereby certify that I am the parent or legal guardian of the above named player.  I

am fully aware of and appreciate the risks associated in participation in the Granite State Lacrosse

Camp and the related sports conditioning activities.  I further agree on behalf of myself, my heirs, and

personal representatives, that Granite State Lacrosse Camp/American Lacrosse Company LLC, along

with coaches, officials, referees, umpires, volunteers, employees, agents, officers and directors of

these organizations, shall not be liable for any personal injury or any other loss or damage whatsoever

occurring as a result of participation in this program.

 

I hereby give consent to the Granite State Lacrosse Camp to provide, through medical staff of its

choice, customary medical/athletic training attention, transportation and emergency services as

warranted in the course of the above named player’s participation.

 

I certify that the above named player is in good health and may participate in all activities as a player

in the Granite State Lacrosse Camp.

 

I give consent for my child to be photographed, videotaped and/or filmed while participating in

activities and for the resulting images to be used by Granite State Lacrosse/American Lacrosse

Company LLC for teaching, promotional and website purposes.

 

As parent/legal guardian of the above player, I hereby verify by my signature below that I have read

and fully understand each of the above conditions for permitting my child to participate in the Granite

State Lacrosse Camp, and I accept each of the above conditions.

 

Parent/Guardian Name:______________________Signature:______________________Date:_____________ 

                                                                                                                                                                                                                                                                                    

Emergency Contact:                                               Tel:                                            Cell:

 

Emergency Contact:                                               Tel:                                            Cell:

 

Family Doctor:                                                         Doctor’s Phone:

 

Special Information regarding medical history: