Athlete First Name *

Athlete Last Name *

Payment Option *
(Select a payment option) Borrow a stick and shin guards from us: $100 Buy a stick and shin guards from us: $150

Athlete Date of Birth *

Address Line 1 *

Address Line 2

City *

State *
North Carolina South Carolina Other

Zip Code *

Parent/Guardian Phone * (ex. 555-555-5555)

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Email *

Confirm Parent/Guardian Email *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone * (ex. 555-555-5555)

Please type below if you have any medical or health considerations that our staff needs to know about:
0

Insurance Information:
Policy Holder

Insurance Company

ID #:

I certify that the registered party has a current physical on file and has been cleared for rigorous activity, with any exceptions therein noted above.

I hereby acknowledge and understand that this activity is a privately run activity, and is not operated by or through Davidson College. The activity is not sponsored, controlled, or supervised by Davidson College, but rather is under the sole sponsorship and supervision of the Club Director, Zoe Almquist.

I hereby acknowledge and understand the refund policy.

I understand and accept the agreement and liability waiver ("Agreement and Waiver").

By entering my name below, I assert that I have reviewed and agree to all the waivers and agreements I selected above.
Name of Parent/Guardian *

Date *

(Note: If you are on a safari desktop browser and cannot get the date to work, try putting it in YYYY-MM-DD format, e.g. 2022-04-10)