Montgomery Lacrosse Registration Form

Waiver and Release of Liability:

I understand that lacrosse is a physical contact sport and hereby give permission to participate in this Montgomery Lacrosse program. I release, waive, discharge and convenant not to sue Montgomery Lacrosse, its directors, agents, coaches, and other employees of the organization of any, and all liability for injuries sustained while participating in this program. I acknowledge that ultimate game scheduling is dependent on various factors, a number of which are beyond the control of Montgomery Lacrosse.

Participant's Health Insurance Company: Policy #: ID #:

I certify satisfactory health to participate in these activities. I hereby authorize the management of Montgomery Lacrosse to obtain emergency medical care for injuries or illness that might occur during this program. I further direct all medical/hospital facilities to accept this document as authorization to render essential care deemed medically necessary in the event I am unable to be immediately contacted.

I/We have read the above waiver and release, understand that I/we have given up substantial rights by submitting this form and do so voluntarily.

Signature: Date:

**Player Data**
Players' Name: Date of Birth: Gender:
Parent's/Guardian's Name:
Address: City: State: ZIP:
Phone: (H): (W): email:
High School or Youth Program:
School Grade:
Years of Experience: Youth JV Varsity Adult
Positions Played: 1) 2)

Day Camp Information

Please check the box next to the day camp(s) you wish to attend.

Selection:

Dates

Location

Cost

Maryland

7/21/2003 - 7/24/2003

Frost Middle School (9201 Scott Drive Rockville, MD 20850)

$235.00

7/28/2003 - 7/31/2003

Frost Middle School (9201 Scott Drive Rockville, MD 20850)

$235.00

PAYMENT INFORMATION

Cost is $235

Method of Payment: Check MasterCard VISA

Day Camp

Office only

CH # ________

AUTH _______

Please make your checks payable to MONTGOMERY LACROSSE

(a $25.00 fee will be charged for all returned checks)

Amount Enclosed:$_____________

Credit Card#: Exp. Date

Signature: __________________________________________

Thank you for choosing Montgomery Lacrosse

FAX completed Registration Form to: 301-762-1164

Faxed applications MUST have credit card number and authorization signature.

Mail Check and completed / signed Registration Form to:

MONTGOMERY LACROSSE

14412 White Tree Place North Potomac, Maryland 20878

For additional information call: 301-928-6580

This program will begin on 7/21/2003 and end on 7/24/2003

Location: Frost Middle School

All participants must provide their own equipment - helmet, arm pads, shoulder pads, gloves, stick, mouthguard, and athletic supporter with protective cup.

We do not rent equipment for league play.

Check this website often for further updates and new programs.

Refund Policy

No telephone refund requests will be honored. Refund requests must be received in writing 14 days prior to first day of camp. No refunds are permitted thereafter for any reason. No refunds will be issued for any reason once the camp begins including illness or injury. All camp refund requests should be sent to the attention of the Camp Director and can be faxed to 301-928-6580 or mailed to 14412 White Tree Place, North Potomac, Maryland 20878 Please include the camper's name and the camp they registered for on the refund request.

All refunds are subject to a $50 administrative fee.

Refund requests can be faxed to (301) 762-1164 or mailed to: Montgomery Lacrosse 14412 White Tree Place North Potomac , Maryland 20878