James Madison University 5 V 5 Tournament
James Madison University 5 V 5 Tournament When: Saturday October 17, 2015 What time: Check in 12:30 p.m.
Skill Instruction 1:00-1:45p.m.
Tournament: 2:00-5:00p.m.
Where: James Madison University Park Fields Who: Any 2016, 2017, 2018, 2019 or 2020 To register as a Team you must have 5 players and a goalie. Teams may not be larger than 8 players. You may register as an individual and we will place you on a team. Applications will be processed on a first come first serve basis. We are accepting only 16 teams! Sign up: Sign up: Cost: $70 per person or $350 per team Individual Player Information
Team Name:____________________
Name: _____________________
My Teammates:
Please make checks payable to JMU Lacrosse.
1. Me Questions: contact Julie via email [email protected] City/State: _________________
2.
5. gar=== 6.
3.
7.
Email: ______________________
4.
8.
Club Team: _________________
Payment: [ ] $350 Team
High School: ________________
Please send $, registration form and Medical form to:
Graduation:_________________ Position: ___________________ We will send you a confirmation email!
[ ] $70 Individual
JMU Lacrosse Julie Gardner 261 Bluestone Drive MSC 2301 Harrisonburg, VA 22807
EMERGENCY HEALTH INFORMATION Applicant’s Name: _______________________________ Mother’s Name: _________________________________
Cell Phone:______________________
Place of employment: ___________________________ Father’s Name:__________________________________
Cell Phone:______________________
Place of employment:____________________________ If Parents/Guardians cannot be reached please call: Name: __________________________ Phone:_______________________ Name: __________________________ Phone: _______________________ Medical Insurance Company: ______________________________________ Policy Number: ___________________________________________________ Are you insured by any other health benefit plan such as HMO, etc… __________________________ Family Physician: _____________________________
Phone: __________________________
Please indicate any serious medical conditions: ______________________________________________ ___________________________________________________________________________________________ Allergic to: ________________________________________________________________________________ MEDICAL INFORMATION ___________________________ has been examined within the last 12 months and no medical reason has been found that she cannot participate in this camp/clinic. Her records show that all immunizations are up to date. Date of last tetanus and diphtheria immunization ___________ If more than 10 years ago a booster shot is recommended. I agree that in the case of an accident involving my child while attending this clinic and with full awareness that lacrosse is an activity that may involve risk or injury, I release James Madison University, their trustees, and servants from any and all liability. In case of an emergency I give permission to the appropriate camp/clinic personnel to have my child properly transported to a medical facility. I understand that James Madison University does not provide medical insurance and that I will be responsible for all
Skill Instruction 1:00-1:45p.m.
Tournament: 2:00-5:00p.m.
Where: James Madison University Park Fields Who: Any 2016, 2017, 2018, 2019 or 2020 To register as a Team you must have 5 players and a goalie. Teams may not be larger than 8 players. You may register as an individual and we will place you on a team. Applications will be processed on a first come first serve basis. We are accepting only 16 teams! Sign up: Sign up: Cost: $70 per person or $350 per team Individual Player Information
Team Name:____________________
Name: _____________________
My Teammates:
Please make checks payable to JMU Lacrosse.
1. Me Questions: contact Julie via email [email protected] City/State: _________________
2.
5. gar=== 6.
3.
7.
Email: ______________________
4.
8.
Club Team: _________________
Payment: [ ] $350 Team
High School: ________________
Please send $, registration form and Medical form to:
Graduation:_________________ Position: ___________________ We will send you a confirmation email!
[ ] $70 Individual
JMU Lacrosse Julie Gardner 261 Bluestone Drive MSC 2301 Harrisonburg, VA 22807
EMERGENCY HEALTH INFORMATION Applicant’s Name: _______________________________ Mother’s Name: _________________________________
Cell Phone:______________________
Place of employment: ___________________________ Father’s Name:__________________________________
Cell Phone:______________________
Place of employment:____________________________ If Parents/Guardians cannot be reached please call: Name: __________________________ Phone:_______________________ Name: __________________________ Phone: _______________________ Medical Insurance Company: ______________________________________ Policy Number: ___________________________________________________ Are you insured by any other health benefit plan such as HMO, etc… __________________________ Family Physician: _____________________________
Phone: __________________________
Please indicate any serious medical conditions: ______________________________________________ ___________________________________________________________________________________________ Allergic to: ________________________________________________________________________________ MEDICAL INFORMATION ___________________________ has been examined within the last 12 months and no medical reason has been found that she cannot participate in this camp/clinic. Her records show that all immunizations are up to date. Date of last tetanus and diphtheria immunization ___________ If more than 10 years ago a booster shot is recommended. I agree that in the case of an accident involving my child while attending this clinic and with full awareness that lacrosse is an activity that may involve risk or injury, I release James Madison University, their trustees, and servants from any and all liability. In case of an emergency I give permission to the appropriate camp/clinic personnel to have my child properly transported to a medical facility. I understand that James Madison University does not provide medical insurance and that I will be responsible for all
