HOPKINTON PARKS AND RECREATION DEPARTMENT
330 Main Street
Hopkinton, NH 03229
2010
YOUTH LACROSSE REGISTRATION
PLAYER INFORMATION
NAME_________________________________ PHONE #________________________
ADDRESS______________________________________________________________
__________________________________________________________________
E-MAILADDRESS: Player_______________________Parent_____________________
DOB__________ AGE as of (12/31/09)____ SCHOOL___________________GRADE_____
PARENT (GUARDIAN) INFORMATION
PARENT’S NAME______________________________WORK PHONE____________
HOME PHONE___________ EMERGENCY
CONTACT_____________________________________PHONE #_________________
MEDICAL COVERAGE? YES/NO
MED. PLAN NAME______________________________ ID#_____________________
PHYSICIAN NAME______________________________ PHONE #________________
PHYSICIAN ADDRESS___________________________________________________
_________________________________________________________________
Are there any physical conditions of the player that our couches & staff should be aware of?
VOLUNTEER TO HELP
COACH___ TEAM PARENT____ TIME KEEPER____ OTHER_______
I hereby release the Town of Hopkinton, its’ employees and agents from any liability for personal injury, loss or damage to personal property which my family may experience in connection with the Youth Lacrosse program, sponsored by the Hopkinton Recreation Department. I hereby consent to any medical procedures deemed advisable for my child in the event I cannot be reached and my child has sustained physical injury.
Signature of parent or Guardian_______________________________________Date_____________
CHECK PAYABLE TO “HOPKINTON RECREATION DEPT” FOR $65.00
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