For girls who are not on a team already but who want to play indoor lacrosse, use this form to register.  If teams need players, we will call upon the individual applicants to complete their rosters.  If you are not selected, we will return to you the full amount of your payment.  To be eligible, you must be in high school during the 2008-09 school year or be 14 years old by October 6, 2008.  Any exception to this policy must be approved by the program commissioner.  To learn more about the girls' program, go to the the link "PROGRAM INFORMATION."  No beginners, please.

NAME _____________________________    SCHOOL ________________    GRADE _____________

ADDRESS _______________________________________  CITY/TOWN ______________ ZIP ______

TELEPHONE (include area code) _____________________ BIRTH DATE ____ / ____ / ____  AGE ___

E-MAIL ___________________________________________________

FIELD LACROSSE POSITION ________________    SKILL LEVEL:  Excellent ____    Good ____ Fair ____

MOST ADVANCED EXPERIENCE (X)    Rec ___    FRESH/SOPH ____      JV ____      VARSITY ____

FEE:  $ 150.00

PAYMENT INFORMATION:

If paying by check, make it payable to "FASTBREAK LAX" and mail this completed application and check to Fastbreak Lax, 4401 Cottington Rd, Baltimore, MD 21236.

If paying by credit card, fill out the following information and mail this completed form to Fastbreak Lax, 4401 Cottington Rd, Baltimore, MD 21236.

    CHECK ONE:    VISA____    MASTERCARD ____

    NAME (exactly as it appears on your credit card) _______________________________

    CARD NUMBER ______________________________    EXPIRATION  DATE ___________________

    CARDHOLDER'S ADDRESS AND ZIP CODE _________________________________________________

    AMOUNT $ ________________    CARDHOLDER'S SIGNATURE ________________________________

LEAGUE AGREEMENT (to read and signed by your parent/guardian)

I agree NOT to hold Fastbreak Lax, Inc., its personnel and coaches, and Freestate Indoor Sports Arena responsible for any injury to my daughter/ward while playing in this program.  I further agree that my daughter/ward is in good physical health and is fit to play indoor lacrosse.  I understand that my daughter/ward must always wear a mouth guard and regulation eye protection while playing, and that this protective equipment is in good condition.  Fastbreak Lax, Inc. and Freestate Indoor Sports Arena do NOT carry health insurance.  In the event of an injury to my daughter/ward, any payment for medical attention is my responsibility. 

PARENT/GUARDIAN SIGNATURE _____________________________________    DATE _______________