Campers Name__________________________________ Position:      Attack       Midfield       Defense      Goalie

School________________________________________ Roommate__________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Day Camp_____________    Overnight Camp ______________    
( Check one please ) 

Parent Email (mandatory)__________________________________________________________________  

I am Sending my $25.00 Insurance Fee as non-US Lacrosse Member______________

My US Lacrosse Membership Number is ____________________________________  Exp. Date______________________

Sending the Airport Transfer Fee of $35.00 (check here)_________
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I understand that: 1) My child is in good physical condition and has had a physical examination within six months prior to camp;
2) I am hereby waiving and releasing the Great Western Lacrosse Camp, its Director and its Staff from any and all liability for injuries incurred by my child while attending and participating in Camp even if arising from negligence;
3) I will pay all costs incurred by the Camp as a result of any failure by my child to respect and maintain facilities and/or observe Camp rules and regulations;
4) The Camp and its Director are not responsible for my child prior to check-in and after check-out;
5) If my child is found to have possession of drugs, alcohol or weapons on the Camp premises, my child will be sent home immediately and without any refund of fees;
6) I am aware that the Camp and its Director/Staff are not responsible for my child prior to check-in and after check-out from the Dormitory.
In the event that I am unable to give parental consent, I hereby authorize the Physician/Hospital Staff at the nearest Hospital to provide care to include diagnostic procedures and medical treatment as necessary to my child, who is a minor. 
(leave nothing blank)                             
Parental Signature__________________________________________________ Date_____________________

Emergency Contact (Not Parent)____________________________________ Phone________________________
I have enclosed a check/money order in the amount of $_______ to secure my child a position at the Great Western Lacrosse Camp. By signing above,  I understand that my deposit of $300.00 or that portion of my full payment is completely NON-REFUNDABLE after June 1st, 2008.                                                                                                                                           
________________________________________________________________________________________________________________________________
Office Use Only - Do Not Write In This Section
Full________ Date_______  Check #_______           Account Money_______
Deposit________ Date_______  Check #_______     Insurance Fee_________
Remaining________ Date_______  Check #_______     Airport Fee________