2010 Summer Instructional Consent Form: IMLCA Affiliate
Sunday 7/11 to Wednesday 7/14
Please complete and send to:
Tom Gravante, Head Lacrosse Coach
Mount St. Mary’s University
16300 Old Emmitsburg Road
Emmitsburg, MD 21727
(O) 301.447.5356 | (C) 301.471.8206
(Fx) 301.447.6723
| Name: |
____________________________ |
Position: |
A M D G (circle) |
| Address: |
____________________________ |
Age/Grade: |
________________________ |
| |
____________________________ |
HS or Club Team: |
________________________ |
| Roommate: |
____________________________ |
Parent’s Work # |
________________________ |
| (H)/(C) |
____________________________ |
Parent’s
Cell # |
________________________ |
| Email: |
____________________________ |
Emergency contact # |
________________________ |
| Parent’s email: |
____________________________ |
|
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Parent/Guardian consent:
I hereby authorize the Elite 150, Inc. lacrosse tournaments/camps/clinics to act on my behalf according to their best ability in any medical emergency. I verify to the best of my knowledge that the above named applicant is physically able to participate in all lacrosse activities. I, parent/guardian of the above lacrosse player, certify that he is covered by medical/health insurance, and has no chronic ailment or recurrent injury, which might endanger his well-being while participating in lacrosse activities/games. I further understand that lacrosse is a contact sport. As a participant in a contact sport, the player above accepts a certain responsibility to play in a sportsmanlike manner and for the normal, inherent risk of athletic injury. I, the undersigned, waive and forever discharge Mount St. Mary’s University, Tom Gravante, and The Elite 150, Inc. lacrosse tournaments/camps/clinics, its staff, officers, representatives, employees, and successors from any and all rights and claims for damage to person and property while at the lacrosse site or any facilities or building(s) on the campus of Mount St. Mary’s University.
Parent/Guardian Signature___________________________________
Date________________
Please make check payable to: The Elite 150, Inc.
Fees: Day-$300/player includes Lunch and Dinner; Resident-$400/player includes all meals. All consent forms and fees due by Friday July 2nd, 2010.
Intercollegiate Men’s Lacrosse Coaches Association: IMLCA Affiliated |