GREAT WESTERN LACROSSE CAMPS - 2020 PLAYER APPLICATION
Please fill out all requires spaces on this form or we cannot process your application.
Choose your camp *
You must select the camp you want to attend. Please do not skip
Player's First Name *
Your answer
Player's Last Name *
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Date of Birth *
(00/00/0000 format)
Your answer
State *
Your answer
Age *
Your answer
Position *
Please select the position you wish to play at camp. You MUST select one. Please do not skip.
Grade *
Grade your son will complete in June of 2018 (not the grade he is entering in September)
School/Team *
(used to pair roommates)
Your answer
Desired Roommate
Rooms house 4 to 6 players. Please list a player or players you wish to room with while at camp.
Your answer
Parent E-mail *
please ensure accuracy as all communication will be sent to this address
Your answer
Player E-mail
if different than parents
Your answer
Camper Details
DAY/OVERNIGHT *
US Lacrosse Membership Number *
This number is mandatory to attend camp: If you need help finding your number, go to http://usl.ebiz.uapps.net/PersonifyEbusiness/Default.aspx?TabID=266. If you need to become a member, go to: http://www.uslacrosse.org
Your answer
Exp. Date *
Your answer
Airport Transportation *
If you need us to pick up your son from the Airport and/or drop him off, indicate below.
CAMP RELEASE
I understand that:
1) My child is in good physical condition and has had a physical examination by a certified physician within six months prior to camp;
2) I am hereby waiving and releasing the Great Western Lacrosse Camp, its Director and its Staff from any and all liability for injuries incurred by my child while attending and participating in Camp even if arising from negligence;
3) I will pay all costs incurred by the Camp as a result of any failure by my child to respect and maintain University/Camp facilities and/or observe Camp rules and regulations causing property damage;
4) The Camp and its director/staff are not responsible for my child prior to check-in at the University and after Check-out from the University;
5) If my child is found in possession of any drugs, alcohol, cigarettes, fireworks or weapons on Camp/University premises or commits an act of violence or bullying while attending Camp, I am aware that my child will be sent home immediately without any refund of fees.
6) I am aware that the Camp and its Director is not responsible for my child while being transported to and from the Airport, should I be using the transportation services of the Camp.
7) I am aware that we have a zero tolerance for all bullying while at camp and I have discussed bullying with my child.

I am aware that I MUST remit all remaining fees by June 15th and that failure to do so will result in a late fee of $25.00 being charged.

By signing below, I am entering into a legal contract willfully and faithfully. I am aware that my deposit of $400.00 or that portion of my full payment is completely NON-REFUNDABLE for any reason after June 15th, not even for an injury or death in the family.

In the event that my child is injured and I am unable to give parental consent, I hereby authorize the Physician/Hospital Staff at any Hospital to provide care to include diagnostic procedures and medical treatment as necessary to my child, who is a minor.
Camp Release Parental Signature *
for Camp Release
Your answer
Camp Release Sig Date *
for Camp Release
Your answer
Parents Names *
Your answer
Parent's Cell Phone *
(000-000-0000 format)
Your answer
Parent's Work Phone *
(000-000-0000 format) put n/a if not applicable
Your answer
Emergency Contact Name, other than parent *
Your answer
Emergency Contact Phone *
(000-000-0000 format)
Your answer
Great Western Lacrosse Programs Waiver and Release of Liability
Amateur Athletic Waiver and Release of Liability Form
Read Carefully before signing

In consideration of being allowed to participate in any way in a Great Western Lacrosse athletic sports programs, related events and activities, the undersigned acknowledges, appreciates, and agrees that:

1. The risk of injury from activities involved in this program is significant, including the potential for permanent injury and death, and while particular rules, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and, assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS the Great Western Lacrosse Company, its Director, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event {“RELEASEES”}, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without inducement.

This is to certify that I, as parent / guardian with legal responsibility for this participant, do consent and agree to his release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, even if arising from negligence.
GWLP Parent's/Guardian's Signature *
for Great Western Lacrosse Program
Your answer
GWLP Sig Date *
for Great Western Lacrosse Program
Your answer
US Lacrosse Participant Waiver and Release of Liability
for participation in a Great Western Lacrosse Camp Program
Instructions:
1.) Each Player should read the statement below before completing and signing this Waiver & Release Form.
2.) Parents / Guardians should read the statement below before completing and signing this Waiver & Release Form.

Agreement:
In consideration of my membership in US Lacrosse and of my participation in the sponsored activities of the Great Western Lacrosse Summer Camp Program, I acknowledge, agree to and understand that:

1.) Readiness To Compete: Voluntary and of my own free will, I elect to participate as a member of a Great Western Lacrosse Summer camp Program. I will only participate in those US Lacrosse competitions and activities sponsored by Great Western Lacrosse for which I believe I am physically and psychologically prepared to compete.

2.) Readiness To Compete: I hereby give my consent to US Lacrosse and to Great Western Lacrosse, California State University San Msrcos and the host organization of any US Lacrosse sponsored event to provide through a medical staff of its choice, customary medical/athletic training attention, transportation and emergency medical services as warranted through the course of my participation in sponsored lacrosse activities.

3.) Waiver & Release of Liability: I am fully aware of and appreciate the risks associated with participation in a lacrosse event, including the risk of catastrophic injury, paralysis and even death, as well as other types of damages and loss. I further agree on behalf of myself, my heirs, and personal representatives, that US Lacrosse, Great Western Lacrosse, California State University San Marcos, the host organization, and sponsors of any US Lacrosse event, along with their coaches, volunteers, employees, agents, officers and directors of these organizations, shall not be liable for any injury, loss of life or other loss or damage occurring as a result of my participation in the event(s). My signature below is my acknowledgement that I have read and understood every provision of this Waiver and Release of Liability, and that I agree to abide by it.
Parent Signature *
For US Lacrosse Waiver
Your answer
US Lacrosse Membership Number *
Your answer
US Lacrosse Membership Expiration Date *
Your answer
Parent's Medical Statement and Release for Treatment
In case of injury, I hereby give consent for my child to have initial first aid administered by qualified personnel in charge and to be transported to a Physician or Hospital for further treatment if it deemed necessary. In the event that I am unable to give parental consent, I hereby authorize the Physician/Hospital Staff at any Hospital to provide care to include diagnostic procedures and medical treatment to my child who is a minor.
Family Doctor *
Your answer
Doctor's Phone Number *
Your answer
Family Medical Insurance Plan *
Your answer
Policy / Certificate Number *
Your answer
BRIEF MEDICAL HISTORY
Please answer the following questions regarding your son/ward:
injuries requiring medical treatment *
Required
illness requiring hospitalization *
Required
currently under a physician's care *
Required
Takes medication or uses an inhaler *
Required
Is hearing impaired or wears glasses / contact lens *
Required
Has fixed or removable appliances in mouth *
Required
There is a reason for this person to avoid contact *
Required
Has fainted during exercise or lacrosse activities *
Required
Has a history of heart disease or diabetes in the family *
Required
Has any type of physical limitation *
Required
All "YES" responses MUST be explained
If you answer YES to any of the 10 questions, please explain in detail in the area given below. Please mark your explanations with the number of the question you are explaining.
Your answer
My child is allergic or has sensitivity to the following
(bees, milk, medications, etc.)
Your answer
Please list any medical conditions about your child that would be helpful to a physician:
Your answer
Med Release Sig Date *
for medical statement
Your answer
Med Release Signature *
for medical statement
Your answer
One Last Question...
I learned about the camp from: *
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