Fall Small Group *
Player Name *
Player Name
Gender
Date of Birth *
Date of Birth
Address *
Address
Cell Phone *
Cell Phone
Mother's Name *
Mother's Name
Father's Name *
Father's Name
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
$150 for 6 sessions $184 for 8 sessions $200 for 10 sessions
$
Payment *
Expiration Date
Expiration Date
Name on Credit Card
Name on Credit Card
As it appears on credit card
AMATEUR ATHLETIC WAIVER AND RELEASE OF LIABILITY
Signature *
Checking this box certifies that I, as parent or guardian with legal responsibility for the Participant, do consent and agree to the releases provided above.