2010 Elite 80 Lacrosse Camp Application

 

Please fill out completely and neatly, return with payment
Applicant Last Name                                    First                               Middle
Home Address                                            City                State        Zip
Parent/Guardian                                   Emergency Phone        E-mail Address
Team Name                                         Grade as of 5/10            Age         Weight 

Position:  Attack   Midfield    LSM    Defense   Goalie   FOGO   (circle one or more)

Release and Waiver

I understand that lacrosse is a strenuous and dangerous sport and could cause severe injury.
I, the undersigned, parent/guardian of this applicant, a minor, do hereby authorize the Directors,
Staff, Coaches, Agents, and/or medical persons to arrange for, or render care for any emergency
due to injury, including Aid Car, EMS, or emergency room transportation, and consultation or
treatment by medical or dental professionals or specialists.  In addition, I accept full responsibility
for the cost of treatment and I hereby release and discharge the Directors, Staff, and Agents of
the Great Northwest Lacrosse Camp and any sponsoring organizations from any and all claims for
personal injuries.  I agree that pictures taken of camp activities may be used for promotional purposes.

 
Parent/Guardian Signature                            Date               Name (print clearly) 
 

Health Insurance Information:
A photocopy of applicants health insurance card MUST be included with your application.  Your application will NOT be complete without health card information.

Make checks for $285 payable to:      Elite 80 Lacrosse Camp 
                                                                c/o Kris Snider
                                                                2414   5th Avenue West
                                                                Seattle, WA  98119