September 24, 2022 Prospect Day

Camper Name *

First

Last

Camper Date of Birth *

Age(in years) as of Event *

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 *

Club Team

Club Coach Name

Club Coach Phone

Club Coach Email

Email

Confirm Email

Primary Position *

Secondary Position

Highest Level of Play *

Grade as of Fall 2022 *

Expected High School Graduation Year *

Current GPA *

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, Assumption of Risks, and Indemnification Agreement *

I agree to the below statement

In consideration of Berry College allowing the use of a portion of its property or facilities for the purpose of attending RomeGa Lacrosse occurring during the following dates, January 1-December 31, 2022, I (guest or camper) hereby agree to waive and release any and all claims which I or my family may now or hereafter have against Berry College, Inc., its representatives, agents, employees or assigns for any injury, illness, or damage which I suffer, unless proven such claim occurred based solely upon the gross negligence of Berry College, Inc., while on Berry property or attending a camp or activity at Berry. This includes all activities related to the camp or activity including any transportation related to the activity. I and my family agree to fully and completely indemnify and hold harmless Berry College, its representatives, agents or assigns from any claim, action, cause of action, or suit including litigation expenses and attorney fees due to any injury or damage which may have occurred on of or arising out of or in connection with my use of said premises. I, for myself and/or my minor child (if applicable and signatures appear below), acknowledge and understand this means I knowingly and voluntarily assume any and all risks, both known and unknown, appurtenant to the use of said premises for the camp or activity, wherever on Berry’s campus they may occur, and at all times I am present on said premises. If this waiver/Agreement is signed by a parent or guardian below, you hereby acknowledge that this waiver and indemnity shall be binding upon you, any other parents or legal guardians of said minor child, and the minor child to the fullest extent permitted under the law.

Waiver of Liability *

I agree to the below statement

Applying for acceptance of my child to the Rome Ga Lacrosse camp or clinic, I, intending to be legally bound hereby for myself, my heirs, executors, and administrators, wavier and release any and all rights and claims for damages I may have against the Rome Ga Lacrosse camp or clinic, Berry College, Inc., their representatives, agents or assigns for an 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 Rome Ga Lacrosse camps and clinics to act for me according to her 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 Rome Ga Lacrosse retains the right to use photographs of campers taken at camp for future Rome Ga 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 *

2022 Viking Prospect Clinic – September 24, 2022 – $ 125.00

Total Amount

$ 0.00

Share: