2010 Blackwolf Lacrosse High School Summer Clinic 12pm-2pm
June 28, 29, 30, July 1st, 2nd
13832 Redskin Drive Herndon Virginia
$150 Registration Fee per player/ $135 Fee for Blackwolf Select Players
(Please make checks payable to Blackwolf Lacrosse)
PLEASE PRINT CLEARLY BELOW
1. Player Name/School (Last, First) ___________________________________________/________________________________________
2. Address (Street) (City) (State) (Zip): _________________________________________________________________________________
3. E-Mail Address: (PLEASE PRINT CLEARLY)____________________________________
4. Phone _______________________
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 2010 Blackwolf Lacrosse LLC clinic on June 28th, 29th, 30th, July 1st and 2nd I/we agree that:
1. Guaranteed participation is dependent upon receipt of Applicant’s completed application and fee before June 27th, 2010. NO REFUNDS AFTER 6/27/10. No refunds or pro-rated refunds will be issued for any camp, clinic or lesson once it has begun including but not limited to weather, 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.
In connection with the Applicant’s participation in the Blackwolf Lacrosse LLC lacrosse clinic on June 28th, 29th, 30th and July 1st and 2nd, 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________
US LACROSSE MEMBERSHIP #(REQUIRED) ___________________________EXPIRATION(REQUIRED)__________
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