TEAM APPLICATION -  FASTBREAK LAX GIRLS' HIGH SCHOOL 7 ON 7 INDOOR LACROSSE  PROGRAM  2010-11

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.   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 5th.  Make checks payable to:  Fastbreak Lax and mail to Fastbreak Lax  4401 Cottington Rd  Baltimore, MD 21236.

IF PAYING BY CREDIT CARD, COMPLETE THE FOLLOWING INFORMATION   (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 ____ / ____ / ____