FASTBREAK LAX

(Office)  4401 Cottington Road    Baltimore, MD 21236

(Office)  410-931-2331        Fax  410-931-2886        E-mail:  fastbreaklax@comcast.net        Web Site:  www.fastbreaklax.com

YOUTH GIRLS' INDIVIDUAL APPLICATION FORM 2010-11 (for an individual who is not already on a team)

THIS APPLICATION IS TO BE USED BY AN INDIVIDUAL WHO IS NOT ON A TEAM, BUT WHO WOULD LIKE TO JOIN A TEAM.  IF THIS APPLICANT IS CHOSEN TO BE ON A TEAM, IT IS HER PARENT'S / GUARDIAN'S RESPONSIBILITY TO SETTLE FINANCIALLY ON THE PLAYER FEE WITH THAT TEAM'S COACH OR ORGANIZER.

NOTE:  This application form is to be completed and returned to Program Commissioner Chad Roeder.  It can be mailed, faxed, or e-mailed.  See above.  Have your parent / guardian help you fill out this form.

NAME _____________________________________    SCHOOL ____________________________    GRADE ______

ADDRESS ________________________________    CITY/TOWN _______________________________    ZIP ______

PHONE (Include area code) ________________________    E-MAIL _________________________________________

BIRTH DATE _____ / _____ / _____    AGE _____

EMERGENCY CONTACT PERSON ____________________________    PHONE NUMBER _____________________

FOR WHAT AGE LEVEL ARE YOUR APPLYING ? (circle one)    TYKER        LIGHTNING        MIDGET        JUNIOR

FIELD LACROSSE POSITION (circle)    GOALIE    DEFENSE    OFFENSE

DESCRIBE WHAT LACROSSE EXPERIENCES YOU MAY HAVE HAD. _____________________________________

    _______________________________________________________________________________________________

    _______________________________________________________________________________________________

    _______________________________________________________________________________________________

LEAGUE AGREEMENT (to be read and signed by your parent or legal guardian)

I agree NOT to hold Fastbreak Lax, Inc., The Girls' Youth Indoor Lacrosse Program, Fastbreak Lax, Inc. Personnel, and its coaches responsible for any injury to my daughter/ward while playing in this indoor lacrosse program.  I further agree that my daughter/ward is in good physical health and is fit to play indoor lacrosse.  I also understand that my daughter/ward must wear the necessary and correct protective equipment ( to include mouth guard and goggles ) to prevent serious injury, and that this equipment is in good to excellent condition.  I am aware that Fastbreak Lax, Inc. and Freestate Indoor Sports Arena do NOT provide or carry health insurance for players.  In the event of an injury to my daughter/ward, any payment for medical attention is my responsibility.

PARENT/GUARDIAN SIGNATURE ____________________________________    DATE _____ / _____ / _____