Camper Information
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First Name
*
Last Name
*
Email
Address
City
State
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AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
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Home Phone
(xxx-xxx-xxxx)
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Do you have any previous experience?
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Grade next Fall
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Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
N/A
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School
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Which free clinic would you like to sign up for?
Palo Alto : May 2nd : Mitchell Park : 3:00 - 4:00pm
Los Altos Hills : May 16th : Purissima park : 3:00 - 4:00pm
Belmont : June 6th : NDNU : 3:00 - 4:00pm
Mill Valley: May 9th : Tamalpais HS
Mill Valley: May 30th: Tamalpais HS
Saratoga : May 9th : Redwood M.S.
Where did you hear about us?
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Free Clinic
Web Search
My Coach
Word of Mouth / Friend
Flier
E-mail
LaxPower
Nor Cal Lacrosse.org
Bay Area Parent Magazine
school newsletter
other
Emergency Contact Information
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Emergency Contact First Name
*
Emergency Contact Last Name
*
Emergency Phone Contact
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