$250 Down Payment Registration for League (7v7 Teams)

Payment due by January 6th

Register in two easy steps...
Step 1: Fill out the electronic form below.
Step 2: Once completing this form you will be sent to our secure PayPal page to finish.

The remaining amount of $450 will be due by February 15th.

Athlete Information

Full Name*
Address*
City*
State*
ZIP*
Phone (Home)*
Phone (Cell)
Email*
High School*
Grade*
Date of Birth*
Mother's Name*
Father's Name*

Medical Information

Insurance Carrier*
Policy Number*
Physicians Name*
Medical Conditions
Emergency Contact*
I/We give permission for any medical attention necessary to be administered to my/our child by a licensed Medical Professional in the event of an accident or injury until I/we can be contacted. This release is effective for the 2012 season. I /we will assume responsibility for payment of treatments. I/We the parent of the above named child, give my approval for his/her participation in any and all activities of the RPA LLC. during the 2012 season. I/We do further release, indemnify and hold harmless any liability, direct or indirect, from anyone representing the RPA LLC., and/or any of the members, officers, organizers, supervisors, any and all of them. In case of injury to my child, I hereby waive all claims against the organizers. I am the parent/guardian above. I have read the waiver above and agree to all the terms & conditions.
Parent E-Signature *

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