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Where: Glen Farm ‐
Portsmouth, RI
When: Wednesdays ‐
6:00 PM. June 11th Thru August 20th (minus week of July 4th)
First Name
Last Name
Address
City State Zip
Cell Phone
Home Phone
Emergency Phone
E ‐Mail Address
College (if applicable) Years of Experience
Team Name / Captain
US Lacrosse Membership Number
Cost: $80 per person (team discount possible if 15 or more players)
Covers: Insurance, Field Rental, Referees, Team jerseys (UA ‐like shirts)
Checks can be made payable to: Marty Kelly
Mailing Address: 66 Boyd Avenue
East Providence, RI 02914
401.641.4447 ‐ cell / mkelly@rwu.edu ‐ e‐mail
Insurance Information: Coverage for Accidental Injury is required for all participants. In most cases, family or work coverage is
adequate.
Medical Insurance Company:
Name of Insured: Policy Number:
Allergies: Illnesses:
Medication:
Pre ‐Existing Medical Conditions:
Emergency Medical Treatment: I (we) ____________________ being the applicant, parent or Legal Guardian authorize the Portsmouth Summer Lacrosse
League and/or it's agents to request medical treatment as necessary to insure the well being of you and/or
your son.
Signature of Applicant / Parent or Guardian: Date:
The Applicant, the Parent or Guardian where applicable (under 18) is aware that participating
in lacrosse is potentially hazardous activity. I assume all risk associated with participation in this sport
including but not limited to physical contact,fall, field conditions, weather, traffic, and other reasonable
risk associated with the sport.
Signature of Applicant / Parent or Guardian: Date:
Waiver & Release: We the undersigned, for ourselves, our heirs, executors and administrants hereby waive, release and forever
discharge the Town of Portsmouth, The Portsmouth Summer League and their staff, agents, representatives and employees
of and from all rights and claims for damages, injury or loss due to negligence or not, arising out of or in any way relating
to my or my child's participation in this League. I have read and abide by the Portsmouth Summer League rules.
Signature of Applicant / Parent or Guardian: Date:
REGISTRATION: Please write legibly especially your email address
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