TEAM APPLICATION FOR BOYS' HIGH SCHOOL INDOOR LACROSSE PROGRAM  2010-11

TEAM FEE IS $ 2400.  A minimum deposit of $ 500 is to be included with this application.  The balance of $ 1900 is due no later than Tuesday, October 5th.   ONE APPLICATION PER TEAM.  Scroll down if paying by credit card.  Make checks payable to:  FASTBREAK LAX and mail to Fastbreak Lax  4401 Cottington Rd  Baltimore, MD 21236.  The Fastbreak Lax fax number is 410-931-2886.

TEAM'S FULL NAME _______________________________________________________

CHOOSE ONE:        VARSITY A ____         VARSITY B ____         JV A ____          JV B ____

SIGNATURE OF PERSON COMPLETING THIS FORM:  __________________________________________

ORGANIZER / CONTACT PERSON

        NAME ____________________________________   HOME PHONE _____________________

        WORK PHONE _____________________________    CELL ____________________________

        E-MAIL ________________________________________________________

        ADDRESS ________________________________ CITY/TOWN __________________ ST _____    ZIP _______

COACH (complete if different from organizer / contact person)

        NAME ___________________________________   HOME PHONE _______________________

        WORK PHONE _____________________________    CELL ____________________________

        E-MAIL ________________________________________________________

        ADDRESS ________________________________ CITY/TOWN ___________________ST _____    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 and mail this completed form to Fastbreak Lax  4401 Cottington Rd  Baltimore, MD 21236.  Your credit card information will remain confidential.

    CHECK ONE:    VISA____    MASTERCARD____   DISCOVER ____

    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 _____________________________