Birmingham Pop-Up Clinic

Camper Name *

First

Last

Camper Date of Birth *

Grade as of Fall 2023 (Freshman, Sophomore…) *

Graduation Year (2024, 2025, 2026…) *

Camper Phone *

Email *

Email

Confirm Email

Alternate Email *

Email

Confirm Email

Camper Address *

Address Line 1

Address Line 2

City

State

Zip Code

Camper T-Shirt Size *

Any Known Allergies *

Yes
No

List ALL Allergies *

High School Team Name

Club Team

Club Coach Name

Lacrosse Position *

Insurance Company *

Insurance Company Phone *

Group/Policy Number

Policyholder Name *

Emergency Contact Name *

Emergency Contact Relationship to Camper *

Emergency Contact Phone *

2nd Emergency Contact Name

2nd Emergency Contact Relationship to Camper

2nd Emergency Contact Phone

How did you hear about camp? *

Waiver of Liability *

I agree to the below statement

Applying for acceptance of my child to the RomeGa Lacrosse camp or clinic, I, intending to be legally bound hereby for myself, my heirs, executors, and administrators, waive and release any and all rights and claims for damages I may have against the RomeGa Lacrosse camp or clinic, Berry College, Inc., their representatives, agents or assigns for any and all damages and injuries which may be sustained by me or my child in association with this camp/clinic. Also, I hereby authorize the director of RomeGa Lacrosse camps and clinics to act for me according to his best judgment in any emergency requiring medical attention. My child has had a recent physical examination and is physically able to participate in athletic activities, including lacrosse. I further understand that RomeGa Lacrosse retains the right to use photographs of campers taken at camp for future RomeGa Lacrosse Camp Promotion.

Refund Policy *

I have read and understand the below statement

For individual camps a 15% cancellation fee will be charged upon request of a refund, regardless of reason for cancellation*. Refunds will be granted only if cancellation is made 7 days prior to the beginning of that particular camp or clinic. We are not able to offer refunds within 7 days of camps or clinics. Team and Satellite Camp deposits are non-refundable. /// *COVID-19:We will follow all CDC, GA Department of Health and Berry College guidelines and policies related to COVID-19. If necessary, more detailed information will be distributed when we get closer to the start of camp. Should we need to cancel a camp or clinic due to COVID-19, you will receive a full refund or credit on your account (minus a 3% payment processing fee). ///

Signature of Waiver(or Parent/Guardian if Participant is a Minor) *

Available Items *

2023 Birmingham Pop-Up Clinic – $ 85.00

Total Amount

$ 0.00

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