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 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 _____________________________
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