Central Connecticut State University Clinic Form: Monday July 9th, 2018 $60
Please bring an ADDITIONAL $11 for lunch at the dinning hall. Email with any questions ccsuwomenslax@gmail.com
Email address *
First Name *
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Last Name *
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Preferred Name (Nickname)
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Position *
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Grad Year *
Phone Number *
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Email Address *
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Street Address *
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City, State, Zip Code *
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High School Name *
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High School Coach Name *
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High School Coach Phone Number
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High School Coach Email *
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Club Name
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Club Coach Name
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Club Coach Phone Number
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Club Coach Email
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Parent/Guardian Name *
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Parent/Guardian Name
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Emergency Contact Number *
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Emergency Contact -Relationship to Camper *
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Cash or Check (please pay upon arrival-$60) -Made out to CCSU-"WLax" in Memo *
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