Learning Center
Plans & pricing Sign in
Sign Out



									               Thank you for registering for the 2011 GameBreaker Lacrosse Camp at
                              University of Washington - Seattle, WA
                                         Girls- July 11-14
                                 Boys - June 27-30 & July 18- 21
We’re looking forward to seeing you at camp this summer! We hope that this camp will be an unforgettable and
exciting experience for you to improve your skills and work with some of the top coaches and players from across
the country!

Please read the packet below as this information is extremely important. Feel free to call us with any questions at
800.944.7112 or email us at . This packet can be downloaded at,
under “Download Forms”.

Check In                                                      Health Form
        General Camp                                                   IMPORTANT! Campers will not be admitted
        June 27/July 11 or July 18, 12-1PM, at the                     to camp without this form!
    front desk of McMahon Hall.                                        GameBreaker Lacrosse Health Form
        Please Note: Dinner will be the first meal.                         o Please fill out and bring to check in
        All campers should arrive dressed and ready                            on the 1 day of camp.
        to play!                                              Health & Safety
Check Out                                                              We want to ensure your child a safe and
        June 30/July 14 or July 21 at 12 PM at The                     positive environment during their time at
        front desk of McMahon Hall.                                    camp. Drugs, alcohol and cigarettes are
        Parents are encouraged to attend the                           strictly forbidden, and will result in
        morning session of games on the last day                       immediate dismissal from camp without a
        starting at 9 AM! Check out will occur                         refund.
        immediately after the closing ceremony at             Key Deposit
        the dorms.                                                     The School requires a key deposit of $75
Extended Day Campers                                                   per camper. Please bring a check made out
        Beyond the first day, you should plan on                       to “GameBreaker Lacrosse Camps” for $75.
        arriving dressed and ready to play at 8:30                     The check will be returned to the camper at
        AM and being picked up at 8:30 PM after                        the end of camp after they turn in their key.
        the evening session. Lunch & dinner are               Payments
        included.                                                      Final Payments are due in our office by
Camp Address                                                           May 15 . If you have a balance and would
407 Gerberding Hall                                                    like us to charge it to your credit card,
Seattle, WA 98195                                                      please call us at 800.944.7112.
Camp Phone Number                                             Cancellation Policy
GameBreaker Office: 800.944.7112                                       A camp credit will be issued to any camper
                                                                       who must cancel prior to camp. The credit
                                                                       will be for the amount paid by the camper.
                                                                       It is transferable to another family member
                                                                       and is good through the 2011 season.
       Packing List
                Health Form                                             Pajamas
                GIRLS: Lacrosse Stick, Goggles                          Blanket/Sleeping Bag
                BOYS: Stick, Helmet, Pads                               Pillow
                Cleats                                                  Shower Towel
                Mouthguard                                              Brush
                Athletic Socks                                          Toiletries
                T-Shirts                                                Portable Fan!!!
                Shorts                                                  Alarm Clock
                Socks                                                   Sunscreen
                Sweatshirt                                              Spending Money ($30 Maximum)
                Off-Field Clothes                                       Key Deposit Check ($75)
                Bedding Linens                                          Bathing Suit

Spending Money
         It is not recommended that excessive amounts of cash be brought to camp. Please remind your camper to keep any
         spending money in a secure place.

   -   407 Gerberding Hall
       Seattle, WA 98195

                       GameBreaker Lacrosse Camp Health Record & Release Form
Every camper must have this health record filled out for camp and brought to check in. Camps held in the following
states require this form to be completed and signed by a physician before your child can participate at summer camp
(CT, MA, NY, RI).
                                             PLEASE DO NOT MAIL AHEAD
Camp Location: _____________________________________              Other Allergies: :____________________________________
DOB:_______________ Age:_________ Sex:______ ________                                        Medication
Parent/Guardian:____________________________________              Please indicate Yes or NO for over the counter medications
Address:___________________________________________               that may be administered to your child if necessary due to
Home Phone:_______________________________________                injury and/or illness, according to the manufacturer’s
Cell Phone:_________________________________________              recommendations, by the GameBreaker Lacrosse Camps
Work Phone:_______________________________________                Summer Athletic Trainer.
Emergency Contact:__________________________________              Ibuprofen: Y/N                        Robitussin DM: Y/N
Address:___________________________________________               Tylenol: Y/N                          Benadryl: Y/N
Home Phone:_______________________________________                Sudafed: Y/N                          Pepto Bismol: Y/N
                                                                  Antibiotic ointment: Y/N Mylanta: Y/N
                         Health History                           Hydrocortisone Cream 1%: Y/N
Asthma: Y/N                          Loss of Limb: Y/N
Diabetes: Y/N                        Cancer: Y/N                              Immunization History (Please List Dates)
Orthopedic Problem: Y/N              Mono: Y/N                                 Copy of Immunization Record Preferable
Heart Problem: Y/N                   Depression: Y/N              DPT:_________                       Booster: _________
Head Injury: Y/N                     Migraine: Y/N                Polio OPV (Sabin): _________        Booster: _________
Ear Infection: Y/N                   Tuberculosis: Y/N            Measles/Mumps/Rubella (MMR) #1______ #2_______
Please explain all “yes” answers________________________          Meningitis:_________                See form, Td:_____
__________________________________________________                Tuberculin Test: _________          Results: _________
__________________________________________________                Hepatitis B #1:_________ #2:_________ #3:_________
Other serious illness or injury: _________________________        HIB #1: _________ #2: _________ #3: _________
List all current medications (Prescriptions, “over the counter”   Varicella: _________
and herbal)_________________________________________              Restrictions/limitations for camper while at camp?: Y/N
__________________________________________________                If yes, please explain: ____________________________
__________________________________________________                ______________________________________________

                     Health Insurance                                                   Parent’s Authorization
Provider:___________________________________________              My child has had a recent physical on __________ and may
Insurance Provider Phone Number:_____________________             participate in all activities at the GameBreaker Lacrosse
Policy/ID Number:___________________________________              Camp. I give my child permission to be treated by emergency
Policy Holder’s Name & DOB:__________________________             response personnel. I understand that every attempt will be
Mailing address_____________________________________              made to contact me, or the emergency contact, before taking
__________________________________________________                this action. I hereby waive and release the GameBreaker
                                                                  Lacrosse Camps, staff, camp management and sponsors from
                   Physician’s Information                        any liability for any injury or illness incurred while at camp. I
Physician’s Name:___________________________________              UNDERTAND THAT THERE IS A RISK OF INJURY TO MY CHILD
Physician’s Signature:________________________________            AS A RESULT OF CAMP ACTIVITIES, AND KNOWINGLY AND
               (Only needed in: MA, CT, NY, RI)                   VOLUNTARILY ASSUME ALL RISK OF SUCH INJURY. I will be
Address:___________________________________________               financially responsible for any medical attention needed
__________________________________________________                during camp.
                                                                  Parent Signature                              Date
Aspirin: Y/N                          Penicillin: Y/N             **NOTE** All medication will be checked and kept by the
Sulfa: Y/N                            Bee Stings: Y/N             trainer. All prescription medications must be in their original
If yes, does your child carry an Epi Pen: Y/N                     case/box with the legible prescription label; including
Food Allergies: Y/N                                               inhalers. The prescriber’s authorization form must
If yes, please list:____________________________________
accompany all medication and requires the physician’s

To top