Ultimate Orange 2022 Summer Camp Registration

Player Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address (Required) *

US Lacrosse # *

Jersey Size *

Gender *

Male

Female

Date of Birth *

Grade In School Next September *

Position *

Family Information

By filling out this form I am certifying that my child is in good health and has my full permission to participate in a full lacrosse program. My child has no sickness or illness, disease or bodily injury that is contradictory to participation. I fully understand that lacrosse is a contact sport and that physical injury may occur during the course of practice and games. In the event that I cannot be reached I give my full permission for such medical procedures as may be deemed necessary by an examining physician. I also understand that "Ultimate Orange Lacrosse LLC" is not responsible for the loss of any personal items. Also, please note that all pictures/videos taken at camp may be used at the discretion of Ultimate Orange Lacrosse LLC.

Please type your name to agree to the above: *

Mother's Name *

Father's Name *

Home Phone

Emergency Cell Phone: *

Health Insurance Provider *

Are you a member of US Lacrosse? *

Yes

No

If Yes, what is your claim #

Payment Processing

Clinic fees are non-refundable and must be paid in full at the time of registration. All payments are final, unless cancellation is due to a health related emergency. a note from a medical physician is required. confirmations will be sent via e-mail within one week of the date the application is received.

Make checks payable to

Ultimate Orange Lacrosse

24 South Crossing Way

Bethel CT 06801

You can also pay by Venmo @Ultimate Orange