Ultimate Orange 2022 Summer Team Lacrosse 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 *

Short Size *

Gender *

Male

Female

Date of Birth *

Grade In School in September 2021 *

Position *

What Level did you play last season? *

Team Selection *

2025/6

2023/4

Graduation Year

2023

2024

2025

2026

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

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. We reserve the right to cancel practice due to weather related situations. 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.

Payment is made by check, $950.

Please make payable to Ultimate Orange Lacrosse and send to:

24 South Crossing Way

Bethel CT 06801

or by Venmo @UltimateOrange