REGISTRATION FORM/ROSTER

TEAM________________________________________________

COACH______________________________________________

Asst. Coach____________________________________________

Email_________________________________________________

Home Phone#__________________________________________

Fax#__________________________________________________

Age Division___________________________________________

Please Return this entry form and registration fee of $250 made payable to “Petersburg Elite Stars” Attention Ty White, 11801 Chadwick Lane, Petersburg VA, 23805

LIABILITY WAIVER

I herby authorize the staff of Petersburg Elite Stars to act for me according to their best judgment in any emergency requiring medical attention, and I herby waive and release the staff from any and all liability for injuries or illness incurred while at the event.  I have no knowledge of any physical impairment that would be affected by the above named player’s participation in the event, as outlined.  I have read and understand the terms and conditions outlined in this application

Coach Signature______________________________
Date___________________