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Blue Chip Individual Training
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Invitation





 

 

 

 

 

  

Individual Training Program Registration and Consent 
 

Please complete your payment prior to completing this form.  If you have not yet completed payment, click on the menu at the left to go to the Camp Store and complete payment.

PROGRAM:      DIVISION:  

REGISTRATION PACKAGE:

We send Blue Chip reminders and program information by email during the year.  Check the box at the left if you would like to receive these updates 


PERSONAL
  First Name:            Last Name:  
  Street:  
  City:         State:      Zip:
  Home Phone:  
  Parent's Email:    
(All communication will be sent to this E-mail)
  Health Insurance Company:   
Policy Number:
  Name of Policy Holder:
  Athlete's Email:   
  Athlete's Cell Phone:     Birth date:    (mm/dd/yyyy)
  Height:    Weight:
EMERGENCY CONTACT INFORMATION:
  First Name:   Last     Relationship: 
  Street:  
  City:                        State:       Zip:  
  Home Phone:         Work Phone: (include area code)
  Cell Phone:   (include area code)
  Other Emergency Contact Name: Ph:
MEDICAL:
Allergies: Seasonal  Medication  Food   Other  None
Describe Allergy:
Taking Medication: Yes  No (if yes, please describe below)
Describe Medication:
Will the athlete be taking medication during the program session?  Yes  No
CONSENT:
 

I, the undersigned hereby certify that I am the parent or legal guardian of the athlete. I hereby give my permission for the clinic to seek, during the duration of the clinic, the appropriate medical attention for the athlete in the event of an accident, injury, or illness. I will be responsible for any and all costs of medical attention and treatment. I, the undersigned for ourselves and as guardian of   (player's name first and last) understand that Lacrosse is a physical sport and that injuries can take place during play. I understand that, as with any other sport, injuries can occur and I hereby acknowledge that my child is physically fit and mentally capable of participating in Lacrosse and the Individual Training Program.

I represent that I have sought the opinion of my child’s physician, (include phone)  and he/she agrees that  our son is fully capable of safely engaging in the  activities. I also understand that it is my responsibility in caring for the athlete listed above, to be fully assured that he is capable of playing in such sport. I, the undersigned for myself, my heirs, executors and administrators, waive, release, and forever discharge Blue Chip Lacrosse,  it’s staff, and representatives from all rights and claims for damages, injury, or loss to person or property which may be sustained or occur during participation in lacrosse activities or while at the individual training program.
 

Authorization to Use of Photographs and Images.
Blue Chip Lacrosse reserves the right to take photographs and videos of activities during all of its programs.  These photos and videos may be posted in any and all materials developed by Blue Chip Lacrosse.

By typing my name in this box I certify that I am the parent or legal guardian of the athlete named above and that I consent to each of the items listed above.
Parent or Legal Guardian Name:    Date:  

 

Please Note:
**Cancellation and Refund Policies :

 

 

Admin