READY for VARSITY LACROSSE

Subtitle

REGISTRATION: Print this page, mail form as well as payment (endorsed to "Adolescent Prevention Programs") to 112 High Street, 2nd Floor, Mount Holly, NJ 08060.  Payments can also be completed through Paypal - [email protected] (CAMP ONLY).




 

Adolescent Prevention Programs and Learning Experiences, INC

READY4VARSITY LACROSSE REGISTRATION FORM 

CAMP:   August 1-3 (8/4 RAIN DATE)

 READY FOR VARSITY LACROSSE

(Please make checks payable to our sponsor "Adolescent Prevention Programs"


    REGISTRATION

 
June 24-27   8:30am-11:30pm
 
Open to boys 6th though 12th grade (in September 2013) . All players will be required to possess a lacrosse stick, a NOCSAE approved lacrosse helmet, lacrosse gloves, lacrosse shoulder pads, lacrosse arm pads, a mouth piece, athletic supporter and cup.  Participants must be members of US Lacrosse for insurance purposes. Players should bring their own refreshment.
 
PLAYERS NAME (PRINT):___________________    CELL# ____________________________            
 
PARENTS:  ________________________________    CELL #____________________________                          
                                                                                                   HOME# ___________________________
 
BIRTHDATE: _______________________                  GRADE: __________________   
 
PLAYER?S PHYSICIAN: ___________________________  PHONE: ______________________
 
EMERGENCY CONTACT: _________________________  PHONE: ______________________
 
US LACROSSE #: ________________________________
 
Participant Primary Medical Insurance Carrier:  ______________________________ 
Policy Number: _______________________
 
ANY PHYSICAL ALLERGIES AND/OR RESTRICTIONS?  (CIRCLE)        YES         NO
 
IF YES, PLEASE LIST: ______________________________________________________________________________________
 
******************* SIGNATURE IS REQUIRED FOR PARTICIPATION *******************
In consideration of my son?s participation in the Ready for Varsity Summer Camp Program and my participation in US Lacrosse recognized or sanctioned events, I agree to the following:
Waiver and Release:  I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis and even death, as well as other damages and losses, associated with participation in a lacrosse event.  I further agree on behalf of myself, my heirs, and personal representatives, that Notre Dame High School, US Lacrosse, and sponsors of any US Lacrosse recognized or sanctioned event, along with coaches, officials, referees, umpires, volunteers, employees, agents, officers and directors of these organizations, shall not be liable for any injury, loss of life or other loss or damage occurring as a result of my participation in a lacrosse event. I am aware of the US Lacrosse Insurance Plan and it?s coverage.
Medical Attention: I hereby give my consent to US Lacrosse and the Ready for Varsity Lacrosse Program to provide, through a medical staff of its choice, customary medical/athletic training attention, transportation and emergency medical services as warranted in the course of my son?s participation in US Lacrosse recognized or sanctioned events.
Readiness to Compete:  I will only participate in those US Lacrosse competitions or activities in which I believe I am physically and psychologically prepared to participate.
 
 
__________________________________ _____________________________   ___________________ Player                                                                 Printed Name                                           Date  
__________________________________ _____________________________   ___________________ Parent/Guardian                                                              Printed Name                                           Date  
 
          SUMMER 2012 CAMP REGISTRATION FORM
 
June 24-27   8:30am-11:30pm
 
Open to boys 6th though 12th grade (in September 2013) . All players will be required to possess a lacrosse stick, a NOCSAE approved lacrosse helmet, lacrosse gloves, lacrosse shoulder pads, lacrosse arm pads, a mouth piece, athletic supporter and cup.  Participants must be members of US Lacrosse for insurance purposes. Players should bring their own refreshment.
 
PLAYERS NAME (PRINT):___________________    CELL# ____________________________            
 
PARENTS:  ________________________________    CELL #____________________________                          
                                                                                                   HOME# ___________________________
 
BIRTHDATE: _______________________                  GRADE: __________________   
 
PLAYER?S PHYSICIAN: ___________________________  PHONE: ______________________
 
EMERGENCY CONTACT: _________________________  PHONE: ______________________
 
US LACROSSE #: ________________________________
 
Participant Primary Medical Insurance Carrier:  ______________________________ 
Policy Number: _______________________
 
ANY PHYSICAL ALLERGIES AND/OR RESTRICTIONS?  (CIRCLE)        YES         NO
 
IF YES, PLEASE LIST: ______________________________________________________________________________________
 
******************* SIGNATURE IS REQUIRED FOR PARTICIPATION *******************
In consideration of my son?s participation in the Ready for Varsity Summer Camp Program and my participation in US Lacrosse recognized or sanctioned events, I agree to the following:
Waiver and Release:  I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis and even death, as well as other damages and losses, associated with participation in a lacrosse event.  I further agree on behalf of myself, my heirs, and personal representatives, that Notre Dame High School, US Lacrosse, and sponsors of any US Lacrosse recognized or sanctioned event, along with coaches, officials, referees, umpires, volunteers, employees, agents, officers and directors of these organizations, shall not be liable for any injury, loss of life or other loss or damage occurring as a result of my participation in a lacrosse event. I am aware of the US Lacrosse Insurance Plan and it?s coverage.
Medical Attention: I hereby give my consent to US Lacrosse and the Ready for Varsity Lacrosse Program to provide, through a medical staff of its choice, customary medical/athletic training attention, transportation and emergency medical services as warranted in the course of my son?s participation in US Lacrosse recognized or sanctioned events.
Readiness to Compete:  I will only participate in those US Lacrosse competitions or activities in which I believe I am physically and psychologically prepared to participate.
 
 
__________________________________ _____________________________   ___________________ Player                                                                 Printed Name                                           Date  
__________________________________ _____________________________   ___________________ Parent/Guardian                                                              Printed Name                                           Date  
 

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