First Name *
Last Name *
Grade Fall 2014 *
Position *
Middle School AND/OR  Youth Program*
Age as of Sept. 1, 2014 *
Date of Birth (MM/DD/YYYY) *
Age Group Based on US Lacrosse (2014-2015 year)*
My son's skill level for the Clinic*
Years Playing*
Your email address *
Home phone number *
Cell phone number *
Address *
City *
State *
Zip Code *
Emergency Contact *
Emergency phone number *
Name of Insured *
Insurance Provider *
Insurance Policy Number *
Additional Information you would like to give:
LIABILITY RELEASE & WAIVER
Please read the following Liability Release and Waiver and place a check mark if you agree
to the terms then click SUBMIT to send the form.

I have read and accept the terms of the Release and Waiver of Liability,  
Assumption of Risk, Indemnity and Parental Consent, and Use of
Photographs and Images AGREEMENT
(ABOVE)

2014 FALL YOUTH BOYS SILVERBACKS TRYOUT
REGISTRATION FORM