Registration form


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REGISTRATION FORM


PARTICIPANT INFORMATION (PLEASE PRINT CLEARLY)



Last Name: First Name: ___________
Gender:  Female  Male DOB: Age: _ T-Shirt Size_________
School:
Grade attended year 2013-2014:_____________________



Home address:

City: State/Province: Postal/Zip Code:

Telephone: Cell:

Parent email:

US Lacrosse Membership Number :

Mother’s name: Father’s name:




Mother’s day phone: Father’s day phone:




Mother’s cell: Father’s cell: _________________


Person’s Authorized to pick up child:________________________________________________ (Please provide a copy of their ID)




Emergency contact*: Relationship: Phone:



DROP OFF AND PICK UP TIMES

Drop off time:

3:00 PM for 3rd-6th grade campers

• 5:00 PM for 7th-8th grade campers
Pick up time:

5:00 PM for 3rd-6th grade campers

• 7:00 PM for 7th-8th grade campers
Payments: Tuition may be paid by cash or by check.

Make the check payable to: True Grit Lacrosse, LLC.
Camp Cost: $100
Registration fee: $25, which needs to be paid through a US Lacrosse membership. Please pay through True Grit Lacrosse, LLC on uslacrosse.org (If already a member, please provide membership number above)


SIGNATURE OF PARENT OR GUARDIAN DATE




I understand that the program/registration fee is due by June 30th. We do not provide make-ups or refunds for any days missed for any reason. Please do your best to come to True Grit Lacrosse camp every day and on time.


REQUIRES PARENT’S SIGNATURE:

You have our permission, in the event of an emergency and in case we are unavailable, to authorize any physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my child_______________________________________________ as they may deem advisable.
Parent/Legal guardian name________________________________________________Date_______________
Parent/Legal guardian Signature_____________________________________________Date_______________
Student Allergies________________________________________________________________
Student Medical Problems_______________________________________________________________
Doctor______________________________Phone number____________________________________
Insurance carrier______________________Policy number______________________________________


Contact Information

Christopher Sgritta, Camp Director at

(203) 249-9716

Email: csgritta29@hotmail.com


PARENT STATEMENT
I hereby state that (camper’s name) ___________________________________________ is in good mental and physical health condition to participate in the activities provided by True Grit Lacrosse, LLC. I am fully aware that any activity involving motion or athletic activity creates the possibility of a serious injury. I hereby release True Grit Lacrosse, LLC., its employees and its staff from liability to the above named athlete, of the person claiming through him/her, arising from injury to the person or property of the above named athlete occurring in the premises of True Grit Lacrosse, LLC., and Bethel High School, including any event sponsored or sanctioned by True Grit Lacrosse, LLC., and or travel to and from such activities.
I understand that True Grit Lacrosse, LLC, has the right to deny admittance to any student not meeting the standards of the program as it sees fit. I also agree not to hold these parties responsible in the event that my son/daughter/child engages in inappropriate conduct (including, but not limited to disruptive or volatile behavior in or out of camp, etc.) or becomes involved in any activity or with any persons not associated with True Grit Lacrosse, LLC or its scheduled program and that True Grit Lacrosse, LLC., has the right to send him/her home for inappropriate conduct. I further attest that the information contained in this application is correct to the best of my knowledge. In addition, I have agreed to the policy and fee statement and agree to comply.
I hereby give permission to True Grit Lacrosse, LLC, to photograph and/or videotape the student for educational or promotional purposes. ________ (Initial)

Parent Signature_____________________________________________Date___________

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