TEAM APPLICATION -  FASTBREAK LAX GIRLS' HIGH SCHOOL 7 ON 7 INDOOR LACROSSE  PROGRAM  2008-09

Team fee is $ 2175.   A minimum deposit of $ 400 is to be sent in with this application.   If paying by check, make  it payable to:  FASTBREAK LAX and mail check and this completed form to Fastbreak Lax, 4401 Cottington Rd  Baltimore, MD 21236.  If paying by credit card, scroll down this application.  Mail this completed application to Fastbreak Lax, 4401 Cottington Rd  Baltimore, MD 21236.  The balance of $ 1775 is due no later than Monday, October 6th.  ONE APPLICATION FORM PER TEAM.

TEAM'S FULL NAME _______________________________ TEAM COLORS __________________________

CHOOSE ONE (X)    A DIVISION ____       A/B DIVISION ____      B DIVISION ____        C DIVISION ____

ORGANIZER / CONTACT PERSON

        NAME ________________________________________ HOME PHONE __________________________

        WORK PHONE _____________________________    CELL ____________________________

        E-MAIL ________________________________________________________

        ADDRESS __________________________________________ CITY/TOWN _______________________

        STATE  _________________    ZIP _________________

COACH (complete if different from contact person)

        NAME _______________________________________  HOME PHONE ____________________

        WORK PHONE _____________________________    CELL ____________________________

        E-MAIL ________________________________________________________

        ADDRESS __________________________________________ CITY/TOWN _____________________________

        STATE  _________________    ZIP _______

ASSISTANT COACH (write none on the "NAME" line if there is no assistant)

        NAME ____________________________________

        HOME PHONE _____________________________    CELL ____________________________

IF PAYING BY CREDIT CARD, COMPLETE THE FOLLOWING SECTION:

    CHECK ONE:    VISA____    MASTERCARD____

    NAME ( PRINT EXACTLY AS IT APPEARS ON YOUR CREDIT CARD )___________________________

    CARD NUMBER _________________________    EXPIRATION DATE:  Month____ Year ____

    CARDHOLDER'S ADDRESS AND ZIP CODE ________________________________________

    AMOUNT $___________    CARDHOLDER'S SIGNATURE _____________________________