Please Print
Clearly
First Name _______________________________ Last Name
_____________________________
Age (on 6/27/04) _____ Date of Birth ___________ Sex _____
T-Shirt Size S
M L XL XXL
Address
________________________________________________________________________
City/State/Zip _______________________________ Email Address
_________________________
Daytime Phone (
) _____________________ Evening Phone
( )
_____________________
USAT License Number ________________________ ChampionChip
Number _________________
Please list:
_______________________________________________________________________
Emergency Contact: ______________________________ Phone:
( )
_____________________ |
