Name
Address
Town
State
Zip Code
Health Insurace Provider Group ID #
US Lacrosse #
Emergency Contact
Emergency Contact Phone
Phone
Cell
Player Birthdate
Player Grade for 2011-2012
e-mail
Pinnie Size (Adult S/M  L/XL)



Once you hit submit your child will be registered. Registration won't be complete until you Submit payment for your deposit .Thank you.




Payments for Registration can be mailed to
Lady Laker Future Lacrosse Club
104 Intervale Rd
Mountain Lakes, NJ 07046


Summer 2012 Deposit is
$100.00
and non-refundable

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