For office use only:  Received by______________________________Date____________Amount paid_______Check #______

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Registration Form

Program: _____________________________________________________________

 

Season: ________________ Year: _______ Grade: _______      Girl        Boy

Requested Program time (does not always apply):_________________

Individual Registration

 

Player’s Name: ________________________________________________________

 

Address: __________________________   City/State/Zip:______________________

 

DOB: ________ School: ____________________ Email: _______________________

 Shirt Size: YS   YM   YL -OR- AS AM   AL   AXL   AXXL (circle one if applicable)

 

Guardian 1 Name: __________________________ Phone: (h) __________________

 

(c) _________________ (w) ________________   Email: _______________________

 

Guardian 2 Name: __________________________   Phone: (h)__________________

 

(c) _________________ (w) _________________ Email: ______________________

ALL  CONFIRMATIONS WILL BE MADE VIA EMAIL

 

Please complete and return this registration form with the non-refundable individual fee to
The Gym of Springfield, 1823 Camp Lincoln Road, Springfield, IL, 62707 by the registration date for your specified program.

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