2010-2011

Name: _______________________________________________________________ Address: _____________________________________________________________ City: _________________________________________________________________ Phone: _______________________________________________________________ School: ______________________________________________________________ Grade: 3 rd 4 th 5 th 6 th Age: _____________ 7 th 8 th Date of Birth: ______/______/______ Are you a new or returning player? New: ______ Returning: ______ * For returning players ONLY: Last year’s 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 ____________ Date For Official use only: Date: ____________ Fee: $50PD _____NPD _____