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2015 Cardinals Women’s Lax Clinic Fall Clinic High School

Grades 9 - 12 Date: Sunday November, 1st 2015 9:30am - 3:00pm

Smith Field, (turf field) behind Freeman Athletic Center

Cost - $100 REGISTRATION WITH FULL PAYMENT MUST BE RECEIVED BY OCTOBER 28TH Name:____________________________________________________________________

Email

Address:___________________________________________________________________

Home Address:__________________________________________________________________________

City:_________________________________ State:_______________________Zip:__________________

HomePhone:_______________________________________________________________Cell Phone: __________________________________________________________________________Parent/Gaurdain:____________________________________________________________

Parent’s Cell Phone:__________________________________________________________________

High School:____________________________________________________________________________ High School Coach_______________________________________________________________________ Club Team:_____________________________________________________________________

Age:____________________(Entering grade Fall 2015) Preferred

Position_________________________________________________________________

Applicant’s Signature________________________________________________

Date:_________________

The undersigned parent or guardian understands that while participating at the 2015 Women’s Lacrosse Clinic @ Wesleyan University, my daughter will be engaging in physical activity which contains an inherent risk of physical injury, and the undersigned assumes the risk and releases, waives, and covenants not to sue the Women’s Lacrosse Clinic @ Wesleyan University and the President and Trustees of Wesleyan University, their Officers, Trustees, Agents, Employees, and related parties from any and all liability for personal injury, including, without limitation, any and all liability arising from the negligence of Wesleyan, arising out of my daughter’s participation at the 2015 Women’s Lacrosse Clinic. I hereby grant permission for my daughter to attend the 2015 Women’s Lacrosse Clinic and to be treated by a licensed physician or a member of the athletic training staff for any injury, accident, illness or mishap. I hereby agree to pay through my insurance company or otherwise for any medical treatment that may be necessary. I certify that my daughter is in good health and is able to participate in all activities. Parent or Guardian's Signature:____________________________________________________ Date:_____________________________________ MAKE PAYABLE TO: Kim Williams and

SEND TO:

Kim Williams, Head Women’s Lacrosse Coach Wesleyan University ~ 161 Cross St. ~ Middletown CT ~ 06459-0413 If you have any questions please call Kim Williams at (860) 685-2884