Connecticut Sportsplex

Registration Form

 

This form must be completed with payment or $100 deposit for your registration to be accepted.

 

Participant Personal Information

 

(Please circle one)           Athlete           Team Captain           Manager

 

First Name ________________________ Last ____________________________________ DOB _____________

 

Address_____________________________________________________________________________________

 

City__________________________________ State________________ Zip __________________

 

Home Phone ____________________________________ Work Phone __________________________________

 

Cell ________________________­­­____  E Mail______________________________________________________

 

Program/League Information (Fill in all appropriate information)

 

Program Name _________________________________________________   (Please circle one)    Male     Female

 

Session _____________________________ Team Name ____________________________________________

 

Age Group __________________________ Ability Level _____________________________________________

 

 

The above named participant has my permission to participate in activities at the Connecticut Sportsplex. I understand and agree with the Connecticut Sportsplex Fee Policy. The entire remaining balance is due by the start of the 1st game. A credit card authorization will be required to be signed by the customer authorizing Connecticut Sportsplex to debit outstanding balances for payments past due, team cancellations (drops) and any obligated referee or forfeiture fees not paid.

 

 

Signature ____________________________________________________________ Date __________________

 

Payment Information:                                              Total Fee $_______________________________

 

 

FOR OFFICE USE ONLY

 

Fastbook Event No. ________________                               Excel Entry ___                    Register Entry ____               Initials _____

 

Deposit    $ ____________  Date_________   (Please Circle)    Cash             Credit Card        Check #_______     Initials _____

           

2nd Payment $__________  Date_________    (Please Circle)   Cash            Credit Card        Check #_______     Initials _____

           

3rd Payment $__________  Date_________   (Please Circle)     Cash             Credit Card        Check #_______     Initials _____