Camp Registration:

Player Name:____________________________________________________________________

Address:_______________________________________________________________________

City:_________________________________State:____________Zip:______________________

Primary Phone:______________________________________DOB:________________________

Gender:     M     F   Email:__________________________________________________________

Position:                    Attack                    Middie                    Defense                     Goalie

Lacrosse Experience:                    Beginner                    Intermediate                    Expert

Fees: (Match specific camp w/ specific price and do not forget to calculate discount)

Camp Name:___________________________________________________________________

Camp Cost:                                                                                   $___________________

Discount:                                                                                      $___________________

T-Shirt($20):                                                                                 $___________________

Total Payment Enclosed:                                                           $___________________

T-Shirt Style:          Boy's          Girl's                              Size:          S         M         L         XL

Make Checks Payable to:       Patrick DeBolt

                                               46 Bay St.

                                              Atlantic beach NY, 11561-1036

Emergency Contact Information:

Contact Name:__________________________________________________________________

Relationship:__________________________________Emergency Phone:___________________

Health Restrictions/Medication(s):___________________________________________________

_____________________________________________________________________________

This is to certify that ____________________________ my son/daughter is in good health and has

my full permission to participate. He/She has no previous sickness, illness, disease, or bodily injury that

is contradictory to participation. I understand that lacrosse is a contact sport, and that physical injury

may occur during the course of practice or games. I agree to all Shutout Lacrosse registration rules 

and regulations. I give permission for all such diagnostic and medical procedures that may be deemed 

necessary by the examining physician for my son/daughter. Permission is also granted for Shutout 

Lacrosse to use any individual video or photographs taken at the camp in conjunction with future

publicity. We also understand that Shutout Lacrosse is not responsible for any lost or stolen items and

any cancellations due to poor weather is non-refundable. 

Signature:_________________________________________________Date:________________