Name:

E-mail:

Address:

Home Phone:

Work Phone:

Other:

Attending the

clinic as a:

(Please check all that

apply)

_____ New Umpire          _____ Returning Umpire       _____ Team Rep.

_____ Player                    _____ Coach              _____ Other ____________________           

­­­­­­Team Affiliation:

Enclosed with this

pre-registration

form is:

(Please check all that apply)

_____ Pre-Registration Clinic Fee of $15 - includes a US Lacrosse Women’s Rule Book   

          (Must be received by February 16^th.  Clinic fee on February 24^th will be $25 per   

          person)

_____ US Lacrosse membership fee of $50 (umpire)

_____US Lacrosse membership fee of $65

          (Cross-participant: Umpire + _____________________________

_____US Lacrosse Membership Form. (Forms are available at www.Lacrosse.org. The        

          forms will also be available the day of the clinic)

The Clinic fee is required for pre-registration. Other fees can be paid at the clinic.