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 $40.00 ______RT   $25.00______ One-Way

My US Lacrosse Membership Number is ___________________  Exp. Date__________
(If you do not provide a current 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 Goalie 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 ________________

Parents Home Phone_____________________ Work Phone______________________

Medical Insurance___________________________ Policy Number____________

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 Goalie Camp.
By signing above,  I understand that my deposit of $450.00 or that portion of my full payment is completely NON-REFUNDABLE after July 1st.     
       
I have paid my fees online by credit card in the amount of $___________ to secure my child a position at the Great Western Goalie Camp.
By signing above,  I understand that my deposit of $450.00 or that portion of my full payment  is completely NON-REFUNDABLE after July 1st,
including the online service fee.
_________________________________________________________________________________________________________________
Office Use Only - Do Not Write In This Section
Insurance Fee____________ Account Money__________ Airport Fee___________ 

FEE________________ Date_______________ Check #________________