TEAM APPLICATION FOR BOYS' YOUTH INDOOR LACROSSE PROGRAM   2011-12

Fastbreak Lax 

(office)  8050 Old Montgomery Rd  Ellicott City, MD 21043

Office:  410-908-4567 or 410-931-2331        Fax:  443-283-4011         E-mail:  fastbreaklax@comcast.net       Web site:  www.fastbreaklax.com

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

CHOOSE ONE:        TYKER____         LIGHTNING ____         MIDGET ____          JUNIOR ____

SIGNATURE OF PERSON COMPLETING THIS FORM:  ________________________________________

CONTACT PERSON

        NAME ____________________________________   HOME PHONE _____________________

        WORK PHONE _____________________________    CELL ____________________________

        E-MAIL ________________________________________________________

        ADDRESS ________________________________ CITY/TOWN __________________ ST _____    ZIP _______

COACH (complete if different from 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 ________________

TEAM FEES:   TYKERS AND LIGHTNING = $ 1550     MIDGETS AND JUNIORS = $ 1750       This fee covers field rental for 1 practice, 8 games;  referee and assigner payments;  6 lacrosse balls plus game balls;  and office and other operating expenses.  Teams provide their own game jerseys and player equipment.  Coaches do not have to pay referees.  We do this for you.  It is included in your team fee.  There is a MINIMUM DEPOSIT OF $ 300 PER TEAM which is to accompany this application to hold a place for your team.  The BALANCE IS DUE BY MONDAY, OCTOBER 10th.   If more time is needed, contact Steve Burnham at 410-908-4567.

IF PAYING BY CHECK, PAYABLE TO  "FASTBREAK LAX" AND MAIL THIS APPLICATION WITH PAYMENT TO:   Fastbreak Lax  8050 Old Montgomery Rd.  Ellicott City, MD 21043.

IF PAYING BY CREDIT CARD, COMPLETE THE FOLLOWING SECTION AND MAIL THIS COMPLETED FORM TO: Fastbreak Lax  8050 Old Montgomery Rd.  Ellicott City, MD 21043.  (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 _____________________________