School________________________________________ Roommate__________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Day Camper_______                      Overnight Camper _______                              Goalie Camper_______

Email______________________________________  I am Sending $25.00 Ins Fee as a 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;
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)