APPLICATION (Please Print!!!) High School___ Middle School___ (Check One)

1. 2009 AE Lacrosse Fall Clinics/Leagues Ages: Middle School Clinic/League (Grades 6-8) High School Clinic/League (Grades 9-12) Dates: Sunday Mornings, 9:30am-11am October 11th – November 15th, 2009 Location: Connecticut College Field Turf and Grass Practice Field Cost: $125 Per Field Player ($100 Deposit Due) $75 Per Goalie (Must Pay In Full) Make Checks Payable To: Atlantic Elite Lacrosse ***Spots Are Limited For Each Position*** Return By Oct. 5th, 2009: Dave Cornell Connecticut College Athletic Center 270 Mohegan Ave. New London, CT 06320 (O) 860-439-2564 (F) 860-439-2516 APPLICATION (Please Print!!!) High School___ Middle School___(Check One) Name______________________________________________ Address___________________________________________ City______________________State_____ZIP__________ Phone_____________________________________________ Email_____________________________________________ Age____________ DOB________________ School_____________________________________________ Position(s)________________________________________ INSURANCE Health Insurance Co____________________________ Policy #___________________________________________ EMERGENCY MEDICAL SIGNATURE Signing below indicates your agreement to allow the camp to provide emergency and routine medical care for your child. This is also a consent form that says you are aware of the inherent risks associated with a contact sport such as lacrosse. You also agree that your child will heed all rules and regulations of the camp or face dismissal without refund. ________________________ ________________ Parent/Guardian signature Date Consent/Hold Harmless Agreement   I, the undersigned, name, in consideration of the many and varied benefits to be conferred on me by Connecticut College in conjunction with Connecticut College Boys Fall Lacrosse League sponsored by Atlantic Elite Lacrosse held at the Artificial Turf Field at Silfen Field & Track and/or grass fields or the Field House on the campus of Connecticut College do hereby for myself forever release, acquit, and discharge Connecticut College, Atlantic Elite Lacrosse and all of its directors, coaches, and college personnel individually and collectively from any and all claims, demands, actions, and causes of action which I or my representative may have by reason of any injury or illness which may occur as a result of the use of Connecticut College athletic facilities.   As further consideration, I hereby agree to indemnify and save harmless Connecticut College and all of its personnel individually and collectively against any and all further claims for damages, costs, and expenses by or on my behalf arising out of the use of Connecticut College athletic facilities.   In addition, I represent that to the best of my knowledge and belief I have no physical infirmity or disability. I also give my permission and consent to Connecticut College and Atlantic Elite Lacrosse to act in my behalf to authorize medical treatment should it be required. Applicant Signature_______________________________________________ Date________ Parent/Guardian Signature__________________________________________ Date________ *******Parent/Guardian Signature required for those individuals under the age of 18.