Brian Shanahan Lacrosse School

Name:____________________________________

Birthdate:__________________________________

Address:___________________________________

_________________________________________

City:____________________   Postal Code________

e-Mail:____________________________________

Home Phone No._____________________________

Business Phone No.___________________________

Cell Phone No._______________________________

Emergency Contact No._________________________

Health Card No.______________________________

Level of Lacrosse   (circle one category)

House League               Rep Level    A  B  C  D

Height________________  Weight ______________

Medical Information / Allergies

_________________________________________

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The applicant agrees that the Brian Shanahan Lacrosse School

and/or its proprietors will not be responsible for any accident

and/or loss, however caused and agrees to release the proprietors

from all claims or damages which may arise as a result of or by

reason of such accident or loss. 

_________________________________________

Signature of Parent or Guardian

_________________________________________

Date

I hereby give my permission to Brian Shanahan Lacrosse School to

use and reproduce photographs taken of my child in conjunction

with lacrosse school activities. I agree that all such photographs

shall remain the property of Brian Shanahan Lacrosse School.

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Signature of Parent or Guardian

_________________________________________

Date