CORE LACROSSE, LLC

Winter Boys Lacrosse Clinics

Registration Form

Please fill out completely all of the following sections (Registration, Medical, Insurance and Liability), sign where indicated, and return with your check (payable to "Core Lacrosse") to Core Lacrosse, c/o Mario Lopez, 93 Price Blvd., West Hartford, CT 06119. An incomplete or unsigned form will not be processed - you will be contacted through phone or email to provide missing information.

PLEASE CIRCLE THE SESSION YOU WISH TO SIGN UP FOR BELOW

Session	Day and Time
5^th and 6^th Grade	Saturdays 10:00-11:00 am
7/8^th Grade	Wednesdays 6:00 pm
8/9t^h Grade	Wednesdays 7:00 pm
10 - 12^th Grade	Saturdays 11:00-12:00
11/12^th Grade Defenseman – Attack Specialized Clinic	Saturdays 12:00-1:00 pm

Name

(First)_______________________________(Last)________________________

Street Address__________________________________________________________

City:_______________________________State:_________Zip Code:_______

Home Telephone:_________________Age:________Grade:_______

Email (Parent/Guardian)__________________________________________________

Father's/Mother’s/Gaurdian’s Name___________________________________________________________

Position: Att_______ Mid_______ Long-Pole Mid_______ Def_______ Goalie_______ Don't have one yet_______

Medical Treatment Authorization

I hereby authorize medical treatment and care for my son/daughter

(print full name)_____________________________, that may include routine diagnostic procedures (i.e., physical examination, x-rays, blood and urine tests) and medical treatment as may be necessary. I understand that the consent and authorization granted herein does not include surgical procedures and are valid only during the time that my son/daughter is in attendance (if your son/daughter has any physical condition or requires any treatment or medication that a clinician should be aware of (i.e., allergies, disabilities, etc.) you must provide written notification to the Clinic staff at or before registration. In the event that an illness or injury requires more extensive evaluation, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency and if I cannot be reached, I give my consent for my son/daughter to receive the proper treatment and/or medical services needed to perform any necessary emergency procedures.

Parent/Guardian

Signature________________________________________Dated:__________

Insurance - Contact Information

Player Name:___________________________________________________________

Parent/Guardian Name___________________________________

Phone #’s to call in an emergency: 1^st choice______________

Emergency Contact Person__________________________Phone number__________

(other than parent)

Will you have health insurance for the entire duration of the clinic?

Yes______ No______

Health Insurance Company__________________________________________________________

Identification or Contract #_______________Group/Plan#___________

Parent/Guardian Signature___________________________________________________

Liability Waiver

The undersigned and the undersigned’s heirs, executors and administrators, hereby waive and forever release and discharge Core Lacrosse, LLC, its officers, directors, employees, agents, contractors, successors and assigns of and from any and all claims, suits or rights for damages for personal property or physical injury which may be sustained or which occurs during participation in clinic activities or that may occur to or from clinic, whether or not such injuries or property damage or loss is caused by, is connected to, or arises out of any acts or omissions or the negligence of Core Lacrosse, LLC, its officers, directors, employees, agents, contractors, successors and assigns.

Parent/Guardian

Signature__________________________________________________

_______________________________________________________________

Enclosed is my completed registration form, medical waiver and insurance form and liability waiver, along with a check made payable to “Core Lacrosse” in the following amount:

CLINIC FEES (covers facility dues and lacrosse instruction)

Full payment due with registration

Session
5^th and 6^th Grade	Saturdays 10:00-11:00 am	$205
7 / 8^thGrade	Wednesdays 6:00 pm	$225
8 / 9^th Grade	Wednesdays 7:00 pm	$225
10^th - 12^th Grade	Saturdays 11:00-12:00nn Closed	$205
11/12^th Def – Att Specialized Clinic	Saturdays 12:00-1:00pm	$380

PLEASE NOTE: A fee of $20 dollars will be charged for cancellations prior to January 3, 2009. After January 3, 2009 all fees are non-refundable except in the case of a documented medical emergency. Any returned check is subject to a $20 returned check fee.

Parent/Guardian Signature_________________________________________________

Please send entire registration form with full payment to:

Core Lacrosse

c/o Mario Lopez

93 Price Blvd

West Hartford, CT 06119

If you have any questions or concerns please do not hesitate to contact Mario Lopez at:

chieflax14@yahoo.com

or call 860-463-9919