Paul Rabil's Upper90 Lacrosse > Leagues > Bethesda > Spring 2012

bethesda leagues: spring 2012: registration

First Name:
Last Name:
Email Address:
Nickname:
Suffix (Jr, III, etc):
Birth Date (MM/DD/YYYY):	/ /
Gender:
Home Phone:
Street Address:
City:
State:
Zip Code:
School Name:
Years Experienced:
Position:
Emergency Contact:
Emergency Contact Phone:
Medical Conditions/Problems:
Participant Primary Medical Insurance Carrier or None:
Policy Number or None:
Name of Policy Holder or None:
The participant assumes all risks associated with participation in the UPPER 90 LACROSSE program; UPPER 90 LACROSSE assumes no liability for injury or damages arising from participation in the program. Due to the strenuous nature of some activities, UPPER 90 LACROSSE encourages each participant to consult his or her physician concerning fitness to participate in the program. The participant consents to emergency treatment. The participant also consents to UPPER 90 LACROSSE'S use of any photographs taken or video tapes made of the program. If the participant is a minor, the parent or guardian approves his or her participation in the program. Neither the instructor nor any of the staff are responsible for children prior to or after the scheduled program. I agree to the above terms

location

Richard Montgomery HS
250 Richard Montgomery Drive
Rockville, MD 20814

Walter Johnson HS
6400 Rock Spring Drive
Bethesda, MD 20852

League Dates:

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