Counselor Application

* - required

*First Name:

Middle Name:

*Last Name:

*Address:

*City:

*State:

*Zip Code:

*Email Address:

*Home Phone Number:

- - x

*Cell Phone Number:

- - x

*Date Of Birth:

/ /

*Age:

*Gender:

*Position:

*Please select all of
the camp sessions
which you can work:

*Do you take
Face-offs or Draws?:

*T-Shirt Size:

*Short Size:

*Grade Entering Next
Fall:

Or:

If you graduated please indicate a specific year.

*School Name:

Club Name:

*US Lacrosse #:

Please visit www.uslacrosse.org/membership to obtain a membership or check existing membership status.

*US Lacrosse #
Expiration Date:

/ /

*Emergency Contact
Name:

*Emergency Contact
Phone Number:

- - x

*Emergency Contact
Relationship:

*Accolades:

(chars left: 1000)

Please list any lacrosse/coaching accolades or accomplishments (i.e. 1st Team All-American, Team Captain, Faceoff Win %, etc.).

*Waiver:

Read the waiver information below and check this box to acknowledge that you accept the terms outlined.