2008/2009 Blackwolf Lacrosse Winter Clinic
12/6/08, 12/13/08, 12/20/08, 1/3/09, 1/10/09, 1/17/09, 1/24/09, 1/31/09
13832 Redskin Drive, Herndon, VA 20171
$125 Registration Fee per player
(Please make checks payable to Blackwolf Lacrosse)
PLEASE DO NOT STAPLE CHECK TO FORM
PLEASE PRINT CLEARLY BELOW
1. Player Name (Last, First) _________________________________________________________
2. Address: ____________________________________________________________________________________________
(Street) (City) (State) (Zip)
3. E-Mail Address: (PLEASE PRINT CLEARLY)____________________________________________________________
4. Phone _______________________
5. Yrs. Playing Experience_________
6. School & September 2008 Grade: ___________________________________ 9 10 11 12
Playing Position (Circle One) Attack Midfield Defense Goalie
I or I and my minor child (hereafter “Applicant”) hereby applies for participation as a player or parent of a player in the Blackwolf Lacrosse LLC lacrosse clinic on December 6, December 13, December 20 2008, January 3, January 10, January17, January 24, January 31 2009 and I/we agree that:
1. Guaranteed participation is dependent upon receipt of the FIRST 60 Applicant’s completed application and fee. NO REFUNDS AFTER DECEMBER 5, 2008. No refunds or pro-rated refunds will be issued for any camp, clinic or lesson once it has begun including but not limited to sickness, injury or inability to participate in the program due to scheduling conflicts.
2. All equipment required by the National Federation of State High School Associations must be furnished by and worn by the player including a PROTECTIVE MOUTHPIECE.
3. Blackwolf Lacrosse LLC and Joseph Trigiani, its Officers, Directors, Agents, Coaches, Staff and Officials shall be indemnified and held harmless by Applicant and his/her heirs, representatives and assigns, from and against any suit, claim or other action for personal injury or injury to property which Applicant may sustain from participation in any practice or game or which otherwise may arise out of Applicant’s participation in this clinic;
4. All pages of the signed Registration/Application form must be received by 12/5/08
______________________________________ Applicant Signature Date__________
_____________________________________Parent Signature Consent Date__________
In connection with the Applicant’s participation in the Blackwolf Lacrosse LLC Old Redskin Park lacrosse clinic on December 6, December 13, December 20 2008, January 3, January 10, January 17, January 24, January 31 2009 the undersigned do certify that the Applicant/player is in good health, has no physical impairment restricting him from playing lacrosse, except as herewith provided in writing to Blackwolf Lacrosse LLC, and otherwise is able to participate in the program activities. We (are, are not) attaching a statement explaining special physical limitations and/or required medication, if any, (please indicate if the Applicant/player suffers from allergies, asthma, diabetes, restricted activities, etc.). In further consideration of Blackwolf Lacrosse LLC and Joseph Trigiani, acceptance of this application, the undersigned, both for himself or herself and on behalf of any minor child for whom he or she is submitting this application, hereby agree(s) to indemnify and hold harmless, Blackwolf Lacrosse LLC and Joseph Trigiani, its officers, directors, coaches, staff, workers, volunteers, agents, and sponsors from and against any and all liability, claims, actions, lawsuits, losses, judgments, and demands whatsoever, in law or in equity, arising out of or in any way relating to the Applicant’s participation in any Blackwolf Lacrosse event, including, but not limited to, personal injuries or injury to property sustained or caused by the Applicant during or as a result of participation by the Applicant in a Blackwolf Lacrosse LLC event. The Applicant and/or parent or guardian is aware of the fact that lacrosse is a physically demanding and challenging sport in which serious injuries and death may occur.
I affirm that I / We have read, understand and agree to the conditions set forth and certify that the information that I / We have provided is correct.
______________________________________ Applicant Signature Date__________
_____________________________________Parent Signature Consent Date________
INSURANCE
All players MUST be current members of US Lacrosse to participate in the clinic
US Lacrosse Membership number and expiration_____________________________________________
MEDICAL TREATMENT AUTHORIZATION
The undersigned hereby authorizes Blackwolf Lacrosse LLC and its agents to request medical assistance and to authorize medical treatment for and on behalf of the Applicant as deemed reasonable and necessary by an appropriate medical professional to protect the well being of the Applicant.
_____________________________________Applicant Signature Date _________
_____________________________________Parent Signature Date_________
Please print and mail this form and check to:
BLACKWOLF LACROSSE
24660 BUTTONBUSH TERRACE
STONE RIDGE, VA 20105
Web: www.blackwolflacrosse.com Phone: 703.542.5115 E-mail: coachtrigiani@aol.com