TEAM APPLICATION -  FASTBREAK LAX GIRLS' HIGH SCHOOL 7 ON 7 INDOOR LACROSSE  PROGRAM  2011-12

TEAM'S FULL NAME  (one application per team) _______________________________

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

SIGNATURE OF PERSON COMPLETING THIS FORM:  ______________________________________

ORGANIZER / CONTACT PERSON

        NAME ________________________________________ HOME PHONE __________________________

        WORK PHONE _____________________________    CELL ____________________________

        E-MAIL ________________________________________________________

        ADDRESS __________________________________________ CITY/TOWN _______________________

        STATE  _________________    ZIP ___________

COACH (complete if different from organizer / 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 ____________________________

Team fee is $ 2400 (same as last year's fee).   This fee includes all payments for referees, assigner, scorers, and trainer; six lacrosse balls; field rental; game balls; and Fastbreak Lax operating expenses.  A minimum deposit of $ 500 is to be included in with this application.   The balance of $ 1900 is due by TUESDAY, OCTOBER 11th.  If you need additional time, call Steve Burnham at 410-908-4567.  Make checks payable to:  Fastbreak Lax and mail to Fastbreak Lax  8050 Old Montgomery Rd  Ellicott City MD 21043.

IF PAYING BY CREDIT CARD, COMPLETE THE FOLLOWING INFORMATION and mail to Fastbreak Lax  8050 Old Montgomery Rd  Ellicott City MD 21043.   (Note:  Your credit card information will remain confidential.)

    CHECK ONE (credit card only):      VISA____        MASTERCARD____    DISCOVER ____

    NAME AS IT APPEARS ON THE CARD ___________________________  CARD NUMBER _________________________

    AMOUNT $___________     EXPIRATION DATE:  Month____ Year ____

    CARDHOLDER'S ADDRESS AND ZIP CODE ________________________________________

    CARDHOLDER'S SIGNATURE _____________________________  DATE ____ / ____ / ____