EMW Camp Registration

Choose Camp Session

  Resident Goalie Camp, $175 Goalie and Regular Camp $600 Coed Day Camp $375 Resident Coed Camp, $495

Camper Info

   First Name 
   Last Name 
   Date of Birth  mm/dd/yyyy
   

Resident's Only - One Roommate Request?

Position

  Attack Middie Defense Goalie

Parent or Guardian Info

   First Name 
   Last Name 

   Street Address 
   City 
   State/Province 
   Zip Code 
   Home Phone 
   Cell Phone 
   E-mail (required) 

Please Provide Alternate Emergency Contact:

      First Name 
      Last Name 
      Relationship 
      Cell Phone 
      Home Phone 
      E-mail 

Health Insurance Carrier

Enter Policy Number

Subscriber's Name

Family Doctor's Name

Family Doctor's Number

I/We hereby give our consent to the East Meets West Lacrosse Camp Personnel to provide, through a medical staff of its choice, customary medical/athletic training attention, transportation and emergency medical services as warranted through the course of my participation in sponsored lacrosse activities.

Yes No

I/We are fully aware of and appreciate the risks associated with participation in a lacrosse event, including the risk of catastrophic injury, paralysis and even death, as well as other types of damages and loss. I/We further agree on behalf of myself, my heirs, and personal representatives, that East Meets West Lacrosse Camp, its directors, coaches, volunteers, employees, agents, and the University of California @ San Diego, its officers, staff, and agents shall not be liable for any injury, loss of life or other loss or damage occurring as a result of my participation in the event. Entering our names below is our acknowledgement that we have read and understood every provision of this Waiver and Release of Liability, and that we agree to abide by it.

Yes No