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

1. 2009 AE Lacrosse Winter Clinics/Leagues Ages: Middle School Clinic/League (Grades 6-8) High School Clinic/League (Grades 9-12) Dates: Sundays, January 11 through February 8, 2009 Middle School Clinic- 11am – 12:30pm High School Game 1- 12:30 – 2:00pm High School Game 2- 2:00 – 3:30pm Location: Connecticut College Field House Cost: CHECKS PAYABLE TO “AE LACROSSE” $150 Per Field Player ($100 Deposit Due) $50 Per Goalie (Must Pay In Full) **Spots Are Limited For Each Position** **High School Teammates Will Be Kept Together** Due By Jan. 4th , 2008: Dave Cornell Connecticut College Athletic Center 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 Winter Lacrosse Clinic/League sponsored by Atlantic Elite Lacrosse held at the Artificial Turf Field at Silfen Field & Track and/or grass fields and/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.