Camper Name: ___________________________________Age: ________ Grade In Fall:______
Address: _____________________________________ City: _______________ Zip:_________
Name(s): ________________________________________ Relationship:__________________
Home Phone #: _________________ Cell Phone #:_____________ Work#: ________________
In case of an injury please contact me at one of the numbers above. If I cannot be reached at one of these numbers please contact, ____________________________ @_____________________
In the event of an emergency, and no one at any of the above listed numbers can be reached I ( circle one: AUTHORIZE / DO NOT AUTHORIZE the Shamrock Lacrosse Camp staff to seek medical attention for my child.
Send Registration, Parent Waiver and Check Made Payable to: 2004 Rocks Lacrosse Camp
c/o Jon Ewert, 6260 Bellow Valley Drive, Dublin, Ohio 43016