Transcript Slide 1

2011-2012
Name: _____________________________________________________________
Address: ___________________________________________________________
City: _______________________________________________________________
Phone: _____________________________________________________________
School: ____________________________________________________________
League:
Grade:
Girls
Boys
3rd
4th
5th
6th
Age: _____________
7th
8th
Date of Birth: ______/______/______
Are you a new or returning player? New: ______ Returning: ______
* For returning players ONLY: Last year’s team:
________________________________
* If she is moving up from WNBA (3rd-5th) to Collegiate (6th-8th), please
mark off you are a NEW player and put WNBA under last years team.
Please accept the above named person for participation in the above named event.
I am aware of the risks inherent with this activity, and release the sponsors from
responsibility for any and all liability. I have determined the nature of the planned
activities and feel this participant is of sufficient age, ability, and discretion to
participate. I also agree that the participant is at the discretion of the City of
Fitchburg Recreation Department. Violation of the league rules and regulations
could result in removal from the current team for the remainder of the season.
______________________________________
Parent or Guardian Signature
For Official use only:
Date: ____________
Fee: $60PD _____NPD _____
____________
Date