Campers Name___________________________ Position:    Attack    Midfield    Defense

Address___________________________________ City__________________________

State____  Zip Code_________  Age____ DOB_________ Grade Completed 6/12 _____

School_____________________________ Roommate__________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Day Camp______   Overnight Camp ______  ( Check one please )        

Parent Email (mandatory)__________________________________________________  

Sending $25.00 Insurance Fee as non-US Lacrosse Member________

Sending Airport Transfer Fee of $35.00 _________RT     $20.00_______One Way

My US Lacrosse Membership Number is ___________________  Exp. Date_________
(If you do not provide a current US Lacrosse Membership Number & Expiation Date, you MUST send the $25.00 Insurance fee with this application)

Player Email (mandatory)_______________________________________________________  
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~  
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 Face-Off 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______________

Print Parents Name______________________________________ Parent Cell Phone___________________

Emergency Contact (Not Parent)____________________________________ Phone__________________

I am paying by Check_______________   I paid Online________________
____________________________________________________________________________________________________________
Office Use Only - Do Not Write In This Section

Insurance Fee____________   Airport Fee___________  Account Money__________

Deposit________________Date____________Check #____________