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 <= /b>FASTEST GAME =
      ON FOOT!
INTRAMURAL APPLICATION – BOYS & GIRLS =
Kindergarten – Third Grade 
  =
  =
MEDICAL CONDITIONS:  _____________________________________________________________ 
HEALTH INSURER:  __________________________________________________________________<= /b> 
FAMILY PHYSICIAN:  ___________________________  PHONE #:  ___________________________ 
PARENT AUTHORIZATION
I/We know t= hat participation in the programs run by Wakefield Youth Lacrosse may result in injuries to my/our child.  Protective equipment does not prevent all injuries to players.  In the case of an emergency, if o= ur family physician cannot be reached, I/we hereby authorize my/our chi= ld
 
__________________________ to be treat= ed by another physician.
 
Signed Parent/Legal Guardian: ________________________________ Date: _____________________
  =
WYLA = USE ONLY
ÿ  <= b>CASH        CHECK # : _________        = ;  AMT RECEIVED:<= span style=3D'mso-spacerun:yes'>  _________
 
<= b> RECEIVED BY: ________________ DATE:  ___________________ <= /div>
  NAME:   ____________________________________________ 
ADDRESS:  __________________________________________ 
PHONE # :  __________________________________________
 
EMAIL :  ____________________________________________ 
PARENT /GUARDIAN: _______________________________
 
SIGNATURE:  _________________________________= ______ 
  SCHOOL:  _________________ 
GRADE:    __________________ 
BIRTHDATE:  ______________ 
AGE AS OF 01/01/08:  ________ 
    ÿ=      MALE        ÿ=    FEMALE <= /span>
$85 per pla= yer / $300 max per family
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