Date ______/______/_______

Player Name___________________________________________

Address_______________________________________________

City__________________________________________

Zip___________

Email Address_______________________________________________

Birth Date___/___/_____   Age as of August 31,2009_________

Parent Name___________________________________________

Home/Cell Phone #___________________________________________

Emergency Contact #___________________________________________

Champions Membership:  $60.00  ____

Champions Player Card:   $25.00  ____