2005 WPSLA Underclassman
Tournament Registration Form
I am available and wish to participate in the following
tournaments:
_______Ohio Team
Tournament, June 12 & Rutgers Team Tournament, June 17-19 Cost $450
________Keystone Games Senior
Division - State College, PA, July 22 &23 Cost $200
Name_________________________________________ Home Phone #__________________________
Address_______________________________________ Active Email ___________________________
City____________________________
Zip__________ Grade_____ Birth Date__________________
Mother’s Name __________________________ Father’s
Name_______________________________
Cell Phone#
_____________________________ Cell
Phone #_________________________________
Position: A M D LSM
G School____________________ USLacrosse #______________Exp.__
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Parental Permission
I give my permission for my
son, named above, to participate in the tryouts, any associated practices and
the specified tournaments indicated above.
Medical Consent
I hereby give consent for
routine or emergency diagnostic procedures and treatment of my son in case I am
not available. This consent is good for
the tryout on June 5, 2005 and, if selected, any practice associated with the
team as well as the tournament games. I
acknowledge that I am responsible for all reasonable charges in connection with
the care and treatment rendered during this period.
Parent Signature________________________________________ Date__________________________
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INSURANCE INFORMATION
Policy Holder’s
Name__________________________________
Phone #__________________________
Address_____________________________________________
City ______________________________________
State________ Zip_________
Insurance
Company________________________________
Group
Number________________________
Employer_______________________________________
Insurance ID#___________________________
Address_______________________________________City___________________ST________Zip_____
PLAYER’S HEALTH HISTORY
Allergies_________________________________Current
or Chronic illnesses_______________________
Medications (dosage and
frequency)_________________________________________________________
Other important
info_____________________________________________________________________
Player’s
Doctor_____________________________________Doctor’s
Phone________________________
Emergency contact
name____________________________________Phone_________________________