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info@bluechiplax.com
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 Summer 2012 Lacrosse Program Application
 Blue Chip 225  

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.

You will receive a transaction receipt once payment is completed.  Please note the receipt or transaction ID and enter it in the space provided. 
Enter the Transaction Number or Receipt Number:    (Required)                                                     _______________________________________________________________________________

PROGRAM:           DIVISION:  

INVITATION NUMBER:          REGISTRATION PACKAGE:

Rising Seniors July 2-5,2012 (Grad Year 2013) Bryant University, Smithfield RI
Rising Juniors July 9-12, 2012(Grad Year 2014) Bryant University, Smithfield RI
Rising Sophomore July 16-19,2012  (Grad Year 2015) Bryant University, Smithfield RI

How did you find out about Blue Chip 225:    
Specify if other:

We send Camp Notes, updates, reminders and camp 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:
  Roommate Request: (Optional)
   
SCHOLASTIC
  School:            Grad Year:              
  Primary Position:        (attack, midfield, midfield/fo, LSM, defense, goalie)        
  School Coach:First Name: Last Name:
  School Coach Email:
  Club Coach:   First Name:   Last Name:
  Club Coach    Email:
   
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 camper be taking medication during the camp session?  Yes  No
 
CONSENT:
 

I, the undersigned hereby certify that I am the parent or legal guardian of the camper. I hereby give my permission for the clinic to seek, during the duration of the clinic, the appropriate medical attention for the camper 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 other clinic activities. 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 camper 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,  and/or Bryant University,  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 clinic.
 

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 camper named above and that I consent to each of the items listed above.
Parent or Legal Guardian Name:    Date:

If, after you submit this form, significant changes occur in the information you have entered, please email the changes to us at info@bluechiplax.com  DO NOT CREATE A NEW REGISTRATION ENTRY. 

 

Please Note:
**Cancellation and Refund Policies are based on the DATE of cancellation not the REASON. Cancellation notification must be in writing by email to info@bluechiplax.com. Cancellation prior to 60 days of the start of camp, there will be a $75 processing fee for all refunds. If you cancel within 60 days of the start of camp, $150 will be retained from your camp tuition with the remaining balance refunded in full. Cancellation within 30 days of the start of camp, $300 will be retained from your camp tuition with the remaining balance refunded in full. 
Cancellation within 72 hours of the start of camp there will no longer be any refunds processed.

We DO NOT accept day students - all registered athletes will need to stay in the dorms on campus.
NO EXCEPTIONS!

 

Admin