Registration

Summer 2010 Lacrosse Program Application Blue Chip 225 Please complete your payment prior to completing this form. If you have not yet completed payment, click here to go to the Camp Store and complete payment. You will receive a receipt from PayPal. Please note the receipt or transaction ID (from the top right of your receipt) and enter it in the space provided. Enter Pay Pal Transaction number or Receipt Number: (Required) _______________________________________________________________________________ PROGRAM: (Rising Seniors 6/28-7/1, 2010 - Grad Year 2011) Bryant University, Smithfield RI (Rising Juniors 7/5-7/8,2010- Grad Year 2012) Bryant University, Smithfield RI (Rising Sophomore 7/26 - 7/29 - Grade 2013) Golden Goal Tournament Park, Lake George Region, NY How did you find out about Blue Chip 225: Specify if other:
PERSONAL
	First Name: Last Name:
	Street:
	City: State: Zip:
	Home Phone:
	Parent's Email: (All communication will be sent to this E-mail)
	Health Insurance Company: Policy Number:
	Name of Policy Holder:
	Athlete's Email:
	Athlete's Cell Phone: Birth date: (mm/dd/yyyy)
	Height: Weight:
	Roommate Request: (Optional)

SCHOLASTIC
	School:	Grad Year:
	Primary Position: (attack, midfield, defense, goalie)

EMERGENCY CONTACT INFORMATION:
	First Name: Last Relationship:
	Street:
	City: State: Zip:
	Home Phone: Work Phone: (include area code)
	Cell Phone: (include area code)
	Other Emergency Contact Name: Ph:

MEDICAL:
Allergies: Seasonal Medication Food Other None
Describe Allergy:
Taking Medication: Yes No (if yes, please describe below)
Describe Medication:
Will the camper be taking medication during the camp session? Yes No

Consent:
I, the undersigned hereby certify that I am the parent or legal guardian of the camper. I hereby give my permission for the clinic to seek, during the duration of the clinic, the appropriate medical attention for the camper in the event of an accident, injury, or illness. I will be responsible for any and all costs of medical attention and treatment. I, the undersigned for ourselves and as guardian of (player's name first and last)
understand that Lacrosse is a physical sport and that injuries can take place during play. I understand that, as with any other sport, injuries can occur and I hereby acknowledge that my child is physically fit and mentally capable of participating in Lacrosse and other clinic activities. I represent that I have sought the opinion of my child’s physician, (include phone) and he/she agrees that our son is fully
capable of safely engaging in the activities. I also understand that it is my responsibility in caring for the camper listed above, to be fully assured that he is capable of playing in such sport. I, the undersigned for myself, my heirs, executors and administrators, waive, release, and forever discharge Blue Chip Lacrosse, and/or Bryant University, and/or Golden Goal Lacrosse Park it’s staff, and representatives from all rights and claims for damages, injury, or loss to person or property which may be sustained or occur during participation in lacrosse activities or while at the clinic.
By typing my name in this box I certify that I am the parent or legal guardian of the camper named above and that I consent to each of the items listed above.
Parent or Legal Guardian Name: Date: