The Quick Stix Junior Camp Registration Form.
August 10 -13 (Tues - Fri) at St. George's School, Middletown, Rhode Island
The fee for the four-day camp is $325. Take an additional $25 off one child's fee for an additional sibling registered.
Take $25 off if registered before May 15, 2010.
First Name_____________ Last Name ____________________ Address__________________________ City_______________ State__________Zip_________Phone________________Emergency
Phone_________ Grade as of 9/2010______Age_____ Position________ Yrs. Played________ Sex______ Amount enclosed__________
Email (be clear) address____________________ Nickname (if any)________________
Make checks Payable to: Quick Stix Lacrosse Camp
Mail to: Peter Schmitz
170 Congdon Street
Providence, RI 02906
Camp Giveaways - To be determined (Warrior Mini Stick or equivalent)
Insurance Information Coverage for Accidental injury is required by all participants. In most cases family
health insurance is adequate. Please enclose a copy of the insurance card. Medical Insurance Co. _______________________
Name of Insured:______________________Policy No._______________
I certify that the applicant is in good physical condition to participate in the Quick Stix Lacrosse Camp.
Signature of Parent or Guardian________________________ Date______________
Please describe in detail and be sure to notify the camp at check-in if yes to any of the questions below:
- Allergies?_____________________________________________
- Illnesses?_____________________________________________
- Medication?___________________________________________
Pre-existing Injury?__________________________________________
Emergency Medical Treatment; I (we) being the legal Guardian(s) of the applicant authorize the Quick
Stix Lacrosse Camp and its agents to request medical treatment as necessary to insure the well being of my/our son/daughter.
Signature of Parent/Guardian_____________________________ Date__________
Waiver and Release; We the undersigned, for ourselves, our heirs, executors and administrants waive, release
and forever discharge St. George's School, Quick Sticks Lacrosse, Inc., and the Quick Stix Lacrosse Camp, its staff,
agents, representatives and employees of and from all rights and claims for damages, injury or loss whether due to negligence
or not. Signature of Parent/Guardian______________________________ Date__________
How did you hear about Quick Stix Lacosse Camp? Ad Friend
Internet Search (search engine)?_____________ Mailer ________ Other_______________
Is the camper a member of US Lacrosse? Yes No
US Lacrosse number ___________________
