Child's First Name

Child's Last Name

Child's Birth Date

If yes, with what league/team?

Parent's Name

School attending 2012-2013

Parent's E-mail

Parent's home phone

Parent's work phone

Parent's cell phone

If yes, what are their conditions?

How did you hear about the County Line Regulators?

Child's Middle Name

Child's Age on Aug 1st 2012

O

c

Preferred Jersey Number (please provide top three)

(#1 is reserved for team & not available)

Please Choose Correct Age Division

Parent's home address

Shirt Size

Short Size

Cheer (ages 3-13)$200Flag Football (ages 5-6)$95Midget Tackle (ages 6-7)$200Rookie Tackle (ages 8-9)$200Junior Tackle (ages 10-11)$200Senior Tackle (ages 12-13)$200

Male
Female

Yes, my child has experience.
No, my child does not have any experience.

Yes, my child has a medical condition.
No, my child does not have any medical conditions.

Yes, my child has insurance.
No, my child does not have any insurance.

Yes, I would like to volunteer for the 2012 season.
No, I would not like to volunteer for the 2012 season.

YxsYsmYmdYlgSmMdLgXlg

YxsYsmYmdYlgSmMdLgXlg