Campers Name____________________________ Position:   Attack    Midfield    Defense 

Address__________________________________ City_________________________

State____  Zip Code________  Age____ DOB_________ Grade Completed 6/12 _____

School___________________________ Roommate____________________________
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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 US Lacrosse Membership Number & Expiation Date, you MUST send the $25.00 Insurance fee with this application)

Player Email (mandatory)_________________________________________________  
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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_____________

Print Parents Name________________________ Parent Cell Phone______________

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 Lacrosse Camp. By signing above, I understand that my deposit of $365.00 or that portion of my full payment is completely NON-REFUNDABLE after July 1st, 2012.
    
I have paid my fees online by credit card 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 $365.00 or that portion of my full payment is completely NON-REFUNDABLE after July 1st, 2012, including for the online service fee.    

Office Use Only - Do Not Write In This Section                                                                                                                                       
Insurance Fee_____________Account Money______________Airport Fee____________ 
Deposit______________Date__________________Check #____________________