Name:                                                                    Email:
Address:
Position:                                    # of Years Played:
Grade as of 9/2011:                       USLacrosse #:
 
Waiver and Release : My child is in good health and has my permission to participate in this lacrosse program. I fully understand that lacrosse is a contact sport and injury may occur during the course of practice and games.  In the event that I cannot be reached I give permission for medical attention as necessary by an examining physician.   I also understand that Victory Lacrosse is not responsible for loss of any personal items. 50% Refund or 100% Camp tuition credit will be made prior to July 1st.

Parents Signature:
Phone#:
Emergency Contact Info:


                 Week #1  7/18 - 7/21:                      Week #2  7/25 - 7/29:

Make Checks payable to:  Victory Lacrosse
Send to: 1357 Leland Drive Yorktown Hgts, NY 10598
or Pay by Credit Card

Credit/Debit Card #:                                                                      Exp. Date:
Card Holders Name:                                                        Security Code:



If you have any questions please contact us @ victorylacrosse@yahoo.com
Dave @ 845.216.0819











APPLICATION: