Registration

Please complete your payment prior to completing this form. You will receive a receipt from PayPal. Please note the receipt number and enter it in the space provided. Enter Pay Pal Receipt Number: (Required) _______________________________________________________________________________ PROGRAM: (Rising Seniors 6/29-7/2, 2009 - Grad Year 2010) (Rising Juniors 7/6-7/9,2009- Grad Year 2011) How did you find out about Blue Chip 225: Specify if other:
PERSONAL
	First Name: Last Name:
	Street:
	City: State: Zip:
	Home Phone:
	Email:
	Athlete's Cell Phone: Birth date: (mm/dd/yyyy)
	Height: Weight:
	Roommate Request: (Optional)

SCHOLASTIC
	School:	Grad Year:
	Primary Position: (attack, midfield, defense, goalie)

EMERGENCY CONTACT INFORMATION:
	Guardian First Name: Last
	Street:
	City: State: Zip:
	Home Phone: Work Phone: (include area code)
	Cell Phone: (include area code)
	Other Emergency Contact Name: Ph:
PAYMENT
	Blue Chip 225 I will be paying Blue Chip 225 fee of $645 online.

		Blue Chip Lacrosse 85 Chapman Avenue Fairfield, CT, 06825