PLEASE PRINT AND COMPLETE. BRING ON FIRST DAY OR MAIL IN.

Name & Grade:

Address:

Phone:

Email Address:

Emergency Contact Name & Number:

Participants need full pads, stick, helmet, mouth guard and cup.

Please bring completed and signed registration forms to first day of camp

Credit Cards please use the "Pay Now" button on the "Camps/Clinics" page or if paying by check make checks payable to "Pro Impax". Bring on first day or mail to;

Pro Impax
3 Joe Ent Road
Flemington, NJ 08822

WAIVER & RELEASE OF LIABILITY:  I am fully aware of and appreciate the risks associated with participation in a lacrosse event including the risk of catastrophic injury, paralysis and even death as well as other types of damages and loss.  I further agree on behalf of myself, my heirs, and personal representatives that  Pro Impax, the host facility, along with their coaches, volunteers, employees agents, officers, and directors of these organizations, shall not  be liable for any injury, loss of life or other loss or damage occurring as a result of my participation in the event(s).  My signature below is my acknowledgement that I have read and understood every provision of this Waiver and release of Liability, and that I agree to abide by it.

Parent or guardian Signature: ______________________________ Date: _____________