Parental Consent “I give my consent for the applicant listed below to participate in all aspects of the Maple lakes lacrosse camp. In addition, I authorize the Director and the athletic trainer to act for me according to their best judgment in any emergency requiring medical attention.” __________________________________ Player Name __________________________________ Parents or Guardian Name Date __________________________________ Emergency contact numbers Waiver and Release: We, the undersigned, for ourselves, our heirs, executors, and administrators, waiver, release and forever discharge the L2 Lacrosse Associates and Maple lakes lacrosse camp, its staff, officers, players, agents,, representatives, employees, successors, and assigns of and from and all right and claims for damages to persons or property which may be sustained or occur during play or participation in camp activities, or from camp, whether paid damages, injury or loss are due to negligence or not. __________________________________ Player Name __________________________________ Parent or Guardian Name __________________________________ Date _______________________________________ Player Signature Date ______________________________________ Player signature Date ______________________________________ Parent or Guardian Signature
2008 TEAM AND INDIVIDUAL CAMP
_______________________________________ Parent or Guardian Signature
*Confirmation and directions will be emailed upon receipt of payment, application, and completed health form. The application/health form must be completed in full before a camper will be allowed to participate.
General Information
Coaching Staff
Laurie Anthony Co-Camp Director
*Current Head Coach King’s College
Registration Form
Please make checks payable to:
LL2 Lacrosse Associates
Mail applications with deposit or full payment to:
*Head Coach Haileybury School, UK
July 6th-10th Grade 7th-12th grade
3 sessions per day with games during the night sessions x Each Camper will receive an evaluation at the end of camp. x Camp Counselor in each cabin x Counselor to camper Ratio is 1:12 x Camps are held at the Maple Lakes Sports Camp in Estella, PA (see insert) COST: INDIVIDUAL x $375.00 early registration (Full payment before June 8th) x $400.00 (after June 8th) *must send in deposit TEAM x $350.00 per player for teams with more than 7 players attending. (Full payment before June 8th) x $375.00 per player for teams with more than 7 players attending. (After June 8th) *Must send in deposit
x
*Middle Atlantic Conference Selection *4 year starter, Drew University *IWLCA Regional All American *2006 IWLCA North South All-Star
Laurie Anthony 133 N. River Street Wilkes-Barre, PA 18711
PLAYER INFORMATION Name: ___________________________ Address:_________________________ City/State/Zip:____________________ Phone (home):_____________________ Phone (cell):_______________________ Email:__________________________ School or team contact: _____________ Grade:________ Position: G A M D # of Years of Experience:____________ Shirt Size: S M L XL
Lindsey Eichner Co-Camp Director
*Current Head Coach, Wesley College
*Interim Head Coach, Wilkes University *Assistant Coach, Wilkes University *4 year starter, Washington College *IWLCA All American *Still holds career assist record (136) assists in a season (48) *2 time Centennial Conference selection *Additional coaching staff will include current and post collegiate players. Cancellation Policy: Request for cancellations must be made in writing to the camp director no less than 15 days prior to start of camp. A $150 administration fee is non-refundable. There will be no refunds 15 days prior to camp.
Please complete the entire application and enclose a check for the full amount. *Confirmation and directions will be emailed upon receipt of payment, application, and completed health form. The application/health form must be completed in full before a camper will be allowed to participate.
*$250.00 deposit must accompany application to secure registration. Balance due at registration.
Emergency Contact Information
___________________________________ Player Name ___________________________________ Parent or Guardian Name ___________________________________ Emergency Phone ___________________________________ 2nd Emergency Phone ___________________________________ Emergency Contact Person (If parent of guardian cannot be reached) ___________________________________ Emergency Contact Person Phone
Insurance Information
_____________________________________ Insurance Company
Parent/Guardian Authorization:
This health history (on the reverse side of this form), and all information in the insurance section are correct and complete as far as I know, and the person herein described has permission to engage in all camp activities except as noted. I hereby give my permission to the certified athletic trainer to provide routine health care, administer prescribed medications and seek emergency medical treatment including ordering X-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give my permission to the camp to arrange necessary transportation for my child. In the even I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. I agree to assume full responsibility for any damages to property and person as a result of my child’s actions while at camp. I further agree to reimburse the host facility for damages. I hereby wave and release the host facility, Maple Lakes lacrosse camp, and L2 associates from any and all liability for any injuries occurred by my child while attending camp. Print Name:_________________________ Signature:__________________________ Date:_______________________________
____________________________________ Policy # ____________________________________ Name of Insured ____________________________________ ID # ____________________________________ Relationship to player Is Pre-Approval Required? _____________ ____________________________________ Phone # for Pre-Approval ____________________________________ Family Physician ____________________________________ Physician # Physician Address: ___________________ ___________________________________ ____________________________________
Important:
Please notify the camp if this camper is exposed to any communicable diseases during the 3 weeks prior to attending camp. Immunization Record Please give month and year, or last or occurrence of clinical diseases or enclose a doctor’s copy of immunization record) DTP:____________________________ OR Diphtheria:_______________________ Pertussi:__________________________ Tetanus:__________________________ MMR:____________________________ OR Measles:___________________________ Mumps:___________________________ Rubella:___________________________ Polio:_____________________________ Influenza:_________________________ Chicken Pox:______________________ Hepatitis B:_______________________ ALLERGIES: please circle all that apply Bee stings Food Penicillin Other drugs: Other: _________________ _________________ _________________ _________________ _________________
Health History
Please Print Clearly Medical History: Please circle all that apply. If circled please include past and current dates of occurrences. Anemia _________________ Concussion _________________ Fainting _________________ Eczema _________________ Hepatitis _________________ Measles _________________ Mumps _________________ Scarlet Fever _________________ Tonsillitis _________________ Whopping Cough _________________ Asthma/Hay fever _________________ Diabetes _________________ Epilepsy _________________ German Measles _________________ Hernia _________________ Migraine _________________ Pneumonia _________________ Sinusitis _________________ Tuberculosis _________________ Chicken Pox _________________ Ear Infection _________________ Eyes Lenses/glasses _________________ Heart Disease _________________ Kidney Disease _________________ Mononucleosis _________________ Rheumatic Fever _________________ Stomach Disorders _________________ Venereal Diseases _________________
Other Operations:_____________________ Recent Illness (previous 3 months): ____________________________________ Injuries:_____________________________ Important: Campers with the following conditions must provide written physician's clearance before attending camp. Please return an official letter of physicians clearance for each item circled. Circle all that apply: Fracture within last 6 months Surgery in last year Heart Condition Diabetes Spinal injury Seizure Disorder Loss of Organ Hemophilia State all medications player is currently taking: _______________________________ Will the medication be needed at camp? Circle: Yes No Prescribed medication: If the child brings prescription medicine from home, the parent of guardian must submit written authorization for the administering of each of the medications. Prescription medicine will be stored with the trainers Over the counter medicine will not be administered so child must bring their own if they feel it is necessary.
*If necessary, please bring own epi-pens