Summer Camp Registration « Boys High Impact Lacrosse

PLAYER INFORMATION

Name*

First Last

Gender*

Date of Birth*

Grade Entering*

Position*

School and/or Youth Program*

Years Played*

PARENT/GUARDIAN INFORMATION

Name*

First Last

Email*

Enter Email Confirm Email

2nd Email*

Enter Email Confirm Email

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone

Emergency Contact #*

WAIVER RELEASE: My child is in good health and has my full permission to participate in a vigorous lacrosse program. My child has no previous sickness, illness, disease or bodily injury that is contradictory to participation. I fully understand that lacrosse is a contact sport and that physical injury may occur during the course of practice and games. In the event that I cannot be reached I give my full permission for such medical procedures as may be deemed necessary by an examining physician. I also understand that Hi-Impact Lacrosse, Inc. is not responsible for the loss of any personal items and all registrations are NON-Refundable unless a medical emergency in which a signed doctors note is required.*

I agree

Camp Info

Registration Type*

Week 1: Aliso Niguel HS June 5th-8th
Week 2: Fosina Field June 26th-29th
Week 3: Mercy College July 5th-7th
Week 4: ALMS August 14th-16th

Payment Type*

Check
Credit Card (3% Convenience Fee)

Coupon

Convenience Fee*

Price: $0.00

Total

$0.00

Please make check payable to High Impact Lacrosse Inc.

Mail To:
High Impact Lacrosse Inc.
P.O. Box 1214
Yonkers, NY 10703

Billing Info

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Credit Card*

American Express

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Card Number Expiration Date Security Code Cardholder Name

Summer Camp

Summer Camps 2017

PLAYER INFORMATION

PARENT/GUARDIAN INFORMATION

Camp Info

Billing Info

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