Player Information

Office Use Only Boys High School ______

Girls U19 Fusion _____

Boys Youth 12-14 ____ CHEYENNE LACROSSE CLUB US Lacrosse # ______Registration 2010-2011 Expiration ______PLAYER INFORMATION Player’s Name ______Gender M___ F___ Date of Birth: ______School: ______Grade: ______Parent/Guardian Name: ______Street Address: ______City: ______State: ______Zip: ______PLAYER Email Address: ______PARENT Email Address: ______Parent/Guardian Player Home Phone: ______Home Phone: ______Work Phone: ______Work Phone: ______Cell Phone: ______Cell Phone: ______Emergency Contact: ______Relationship: ______Emergency Contact Phone Number: ______

MEDICAL INFORMATION Myself, or my child named above, is covered by the following medical insurance policy: Name of Insured: ______Insurance Company: ______Phone #:______Policy #:______Group #:______Doctor’s Name: ______Doctor’s Phone #:______List any Allergies: ______

WILLING TO HELP?? The Cheyenne Lacrosse Club is run entirely by volunteers. We need your help and support, and value family involvement. Please sign up for one of the duties listed on page 2. Training for coaches is required and is provided through US Lacrosse. REGISTRATION FEES (Non Refundable) The Cheyenne Lacrosse Club registration fee is used to cover the club’s cost for field equipment, city field rental/maintenance fees, referee fees, and US Lacrosse membership. It DOES NOT include the cost of tournaments team’s elect to participate in, or uniforms. Current fee: $130.00 per player. **PLEASE MAKE CHECKS PAYABLE TO: CHEYENNE LACROSSE CLUB SELECT ONE: ___HIGH SCHOOL BOYS (9-12 grade) ___Youth Boys (12-14 yrs) ___Girls U19 (7-12 grade) ***PLEASE READ CAREFULLY*** As parent or guardian, I hereby give full permission for my child named below to participate in the Cheyenne Lacrosse Club program. I fully understand that participation in any sport involves the possibility of injury. A physical examination has revealed no defect or disability which might make my child’s participation hazardous. As parent or guardian, I will review the Association’s Code of Conduct for lacrosse participation with my child, and agree to abide by the guidelines for good sportsmanship and respect for teammates, coaches and officials. I hereby absolve the Cheyenne Lacrosse Club, its officers, officials, managers, coaches and volunteers of liability for injury to my child arising out of game or practice activities, including travel to and from these activities necessary or essential thereto. Furthermore, I hereby give permission for any Association representative to transport, or have transported, my child to a medical treatment facility and to authorize treatment of my child for any injury or medical matter deemed appropriate by the Association representative in my absence. I understand that I will be responsible for any medical fees incurred for treatment of my child. Signed: ______Print Name: ______Date:______(Parent or Legal Guardian)

Return all registration documents to: Regina Meena **please make checks payable to: Cheyenne Lacrosse Club RE: CLC Registration 1189 Deerbrooke Trail Cheyenne, WY 82009

Additionally, I (______) would like to help with (circle one): (name)

1) Team Pictures 2) Team Player Registration 3) Practice/Coaching 4) Equipment Management and Fee Collection 5) Sponsorship Committee 6) Game Scheduling 7) CLC Web Site Update 8) Other______