Registration Form

Name of Player	_____________________________________________________________
Parents/Guardians	_____________________________________________________________
Street Address	_____________________________________________________________
City	_____________________________________________________________
State	_____________________________________________________________
Zip Code	_____________________________________________________________
E-mail	_____________________________________________________________
Telephone (Home)	_____________________________________________________________
Telephone (Work)	_____________________________________________________________
Telephone (Cell)	_____________________________________________________________
Can you receive text?	____Yes ____No
E-Mail	_____________________________________________________________
Player's Date of Birth	_____________________________________________________________

Player Referred By	_____________________________________________________________

Volunteer Participation:

Following is a list of area in which the Lassie League needs volunteers in order to make the season a success. Please check all that interest you:

Coach___	Ass't Coach___	Team Parent___	Umpire___
Board Member___	Scorekeeper___	Banner Maker___	Team Sponsor ($250.00)___
League Sponsor (Specify amount): _______		Other________________________________________________

What size T-Shirt will your child need?

__YXS __YS __YM __YL __YXL __S __M __L __XL __XXL __XXXL

Hospital Authorization:
Potomac Hospital, Woodbridge, VA Authorization for Treatment for Minors
in absence of parent or guardian

I give permission fto Officials of the Prince William Lassie League to authorize emergency treatment at the Potomac Hospital Emergency Care Center for my child:

__________________________________	_____	________	_____________________________________
Full Name of Child	Age	Date of Birth	Dates of last DPT/Tetanus shot

This form is valid from April 1, 2012 until 23 June 2012.

Name of Family Physician/Pediatrician:	______________________________________________________
Phone of Family Physician/Pediatrician:	______________________________________________________
Please list illnesses, allergies, and routine medications given to child:	______________________________________________________ ______________________________________________________

NOTE: An effort will be made prior to the use of tis form to contact you should your child require emergency medical treatment. The PWLL will not be held responsible for any monetary charges for such treatment.

IF YOU HAVE BEEN CONTACTED BY TELEPHONE ABOUT ILLNESS OR INJURY TO YOUR CHILD, YOU ARE REQUESTED TO CONTACT THE POTOMAC HOSPITAL EMERGENCY CARE CENTER AT (703) 670-1363 PRIOR TO LEAVING YOUR HOME OR OFFICE. THIS WILL FACILITATE THE HOSPITAL'S PROVIDING YOUR CHILD IMMEDIATE CARE.

Signature of Parents / Legal Guardians (preceding information is correct):

____________________________________
Signature

_________
Date

Payment Options

MasterCard___

VISA___

Check___

Cash___

Credit Card Number

Sec Code

Exp Date

______________________________	_____________________________
Printed Name	Signature

Bring this completed form to one of our walk-in registration sessions (January 28, February 4, 11, 18, and 25, and March 3) at the AMF Bowling Center on Dale Blvd, or mail your completed and signed form, along with your registration fee (1 girl = $70, 2 sisters = $120, 3 or more sisters = $140), to:

PRINCE WILLIAM LASSIE LEAGUE
PO Box 1706
Woodbridge, VA 22195-1706

PRINCE WILLIAM LASSIE LEAGUE PO Box 1706 Woodbridge, VA 22195-1706

2012 SEASON LEAGUE REGISTRATION FORM

PRINCE WILLIAM LASSIE LEAGUE
PO Box 1706
Woodbridge, VA 22195-1706