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 Jack Reid, 112 Federal St., West Hartford, CT 06110.  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
3rd and 4th Grade	Saturdays 9:00 – 10:00 am
5th and  6th  Grade	Saturdays 10:00-11:00 am
7/8th  Grade	Tuesdays 6:00 pm
8/9th Grade	Tuesdays 7:00 pm
10 - 12th  Grade	Saturdays 11:00-12:00
11/12th 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
3rd and 4th Grade	Saturdays 9:00 – 10:00 am	$205
5th and  6th  Grade	Saturdays 10:00-11:00 am	$205
7 / 8th  Grade	Tuesdays 6:00 pm	$225
8 / 9th Grade	Tuesdays 7:00 pm	$225
10th - 12th Grade	Saturdays 11:00-12:00nn	$205
11/12th Def – Att Specialized Clinic	Saturdays 12:00-1:00pm	$380

PLEASE NOTE: A fee of $20 dollars will be charged for cancellations prior to December 26, 2009.  After December 26th, 2010 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 Jack Reid

112 Federal Street

West Hartford, CT 06110     

 

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

chieflax14@yahoo.com

or call 860-463-9919