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 here to go to the Camp Store and complete payment. You will receive a receipt from PayPal. Please note the receipt or transaction ID and enter it in the space provided. Enter Pay Pal Transaction number or Receipt Number: (Required) _______________________________________________________________________________ PROGRAM:
DIVISION:
ELITE NUMBER:
(Rising Seniors 6/27-6/30, 2011 - Grad Year 2012)
Bryant University, Smithfield RI
(Rising Juniors 7/4-7/7,2011-Grad Year 2013
Bryant University, Smithfield RI
(Rising Sophomore 7/11 -7/14, 2011- Grade 2014 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.
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PERSONAL |
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First Name:
Last Name: |
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Street: |
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City: State: Zip: |
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Home Phone: |
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Parent's Email: (All communication will be sent to this E-mail) |
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Health Insurance Company:
Policy Number:
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Name of Policy Holder: |
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Athlete's Email: |
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Athlete's Cell Phone: Birth date: (mm/dd/yyyy) |
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Height: Weight: |
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Roommate Request: (Optional) |
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| SCHOLASTIC |
| | School: |
Grad Year:
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Primary Position:
(attack, midfield,
midfield/fo, LSM, defense, goalie) |
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School
Coach: First Name:
Last Name: |
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School
Coach Email: |
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Club
Coach: First Name:
Last Name:
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Club Coach
Email: |
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| EMERGENCY CONTACT INFORMATION: |
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First Name: Last Relationship:
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Street: |
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City:
State: Zip: |
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Home Phone: Work Phone: (include area code) |
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Cell Phone: (include area code) |
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Other Emergency Contact Name: Ph: |
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| MEDICAL: |
| Allergies: Seasonal Medication Food Other None |
| Describe Allergy: |
| Taking Medication: Yes No (if yes, please describe below) |
| Describe Medication:
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| Will the camper be taking medication during the camp session? Yes No |
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| 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.
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| 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. |
