Super Soph Lacrosse Combine

(*) denotes required information.
A $200 non-refundable deposit must be received by the lacrosse camp office in order for this registratino to be activated.

Camper Information:
* First Name:
* Last Name:
* Address:
* City:
* State:
* Zip:
* Phone:
Email:
* Age:
* Date of Birth:
* School:
* Grade entering in 2008-09:
* Select your position:
A M D GK

Roommate Request:
Please write down one name if you have a preference.

Medical Consent:
In the event of an emergency, please list two people we can contact:
* Primary Contact:
* Relationship to Camper:
* Phone Number:
Alternate Phone Number:
Secondary Contact:
Relationship:
Phone Number:

* Does the camper have any known food or drug allergy?
Yes No
If yes, please list the food and/or drugs:
* Please provide the date of the latest DPT/Tetanus Toxoid Injection:
* Does the camper have any ongoing disease, physical disability or recurring illness that may affect or impair participation in this camp?
Yes No
If yes, please send a physician's note describing the disability and specific limitation for participation.

Insurance Information:
All campers must have their own medical coverage. Campers will not be allowed to participate unless the following information is submitted.
* Insurance Company:
* Policy Number:
* Phone Number:
Address:
City
Zip:

Prospective students