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RETURN TO: Jon Moriarty c/o GOOD TO GO LACROSSE P.O. Box 805 McMurray, OA 15317

Name: ________________________________ Address: ______________________________ City: _______________State_____Zip_______ Home Phone: ___________________________ Age: ______Birth Date______Position_______ Current Grade:__________________________ Years of lacrosse experience: ______________ School: _______________________________ US Lacrosse Number:____________________ Parent or Guardian: ______________________ I hereby authorize the staff of Big Shot to act for me in the according to their best judgement in any emergency requiring medical attention, and hereby release, discharge, and hold harmless Big Shot from any and all liability incurred at camp. I understand and assume the hazards and risks associated with this activity and waive all claims against Big Shot and staff. Parent / Guardian signature: ________________ ENCLOSED IS MY COMPLETED APPLICATION AND $25.00 PLEASE MAKE CHECKS PAYABLE TO: Good to go lacrosse FOR OFFICIAL USE ONLY Date:__/__/____________Full_______________ Check #________________________________ Balance paid in:________________Cash                            ________________Check