MEDICAL INFORMATION .QUEENER CAMP WAS CREATED TO CREATE INDIVIDUAL GROWTH IN A COMPETITIVE, FUN FILLED ENVIRONMENT. EACH CAMPER WILL RECEIVE INSTRUCTION IN QUEENER NAME______A HYBRID FORM OF BOX AND . PLEASE LIST ANY SPECIAL MEDICAL THIS COMBINES THE STICKWORK, SPEED AND LACROSSE CAMP CONDITIONS, ALLERGIES OR MEDICATION CREATIVITY OF WITH THE NEEDS______STRUCTURE AND TEAM CONCEPTS OF FIELD ______LACROSSE. ______THE COST OF CAMP IS $135 – CHECKS PAYABLE ______TO PENN YAN BOYS LACROSSE

Queener Camp is fully insured, however some injuries can be covered by your own insurance. Please list insurance information below

Policy Holder______

Insurance Company______

Policy #______

I authorize Queener Camp and their medical staff to make decisions for me in case of an emergency. I understand that lacrosse is a contact sport and while every attempt will be made to ensure each participants safety the risk of significant injury is a possibility

Parent Signature______QUEENER CAMP AUGUST 3rd - 5th Camper Signature______QUEENER LACROSSE PENN YAN SCHOOLS

2963 RT 54A UPPER FIELDS Keuka Park, NY 14478 Phone: 315-719-1770 GRADE 3 -12

Camp Schedule Sign -up Form CAMPER NAME-______CAMP STAFF 8:45am Camper Check In- Drop off in parking lot near upper fields behind ADDRESS______PYE- use entrance on Court Street PHONE______behind High School EMAIL______

BRETT QUEENER- 2x MLL WORLD CHAMPION, 9am Morning Session GRADE IN 2013______AGE______MLL- AND NLL BOSTON - Individual Skill Development BLAZERS, UNIV. OF ALBANY ALL AMERICAN, EMERGENCY CONTACT INFORMATION MLL SKILLS CHALLENGE WINNER, 2X - Position Skills PERSONALITY OF THE YEAR, HS ALL Name AMERICAN AT PENN YAN - 4x MLL ALLSTAR - Team Concepts Address

BRICE QUEENER- HEAD COACH AT RHODES Focus on development of all around skills COLLEGE, FORMER HAMILTON NATIONAL AND and expanding your game Phone ROCHESTER RATTLER, 4 YEAR STARTER AT 12Noon Lunch- CAMPERS PROVIDE GEORGETOWN UNUVERSITY

Method of Payment:

1pm Afternoon Session $135 Cash- $135 BRIAN HOBART- HEAD COACH PENN YAN ACADEMY, FORMER ASST COACH MLL - Team Concepts and Drills HAMILTON NATIONALS, HEAD SCOUT FOR Check Number-

ROCHESTER KNIGHTHAWKS - Games (10v10, 7v7, 4v4 and PLEASE MAKE CHECKS PAYABLE TO PENN YAN BOYS LACROSSE Brett’s Special Full Goal, Trash

Can lacrosse MIKE MANLEY- MLL ROCHESTER RATTLERS,

MLL PHILADELPHIA WINGS, DUKE UNIVERSITY - Contests ALL AMERICAN, NCAA NATIONAL CHAMPION, 3pm Dismissal HS ALL AMERICAN AT PENN YAN, MLL ALLSTAR Please Mail completed forms to 2013 address below

PLUS APPEARANCES BY OTHER MLL AND NLL PLAYERS QUEENER LACROSSE

2963 RT 54A Keuka Park, NY 14478 Phone: 315-719-1770 PRIZES AND GIVE AWAYS EVERYDAY!!! Email: [email protected]