{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fswiss\fprq2\fcharset0 Verdana;}{\f1\fnil\fcharset0 Courier New;}} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\b\f0\fs28 Legion of Allstars\fs24\par \fs20 \b0\fs18 1715 Highway 16 West\par Griffin, GA 30223\par 770-412-0033\fs20\par \fs14\par \ul\b\fs16 Registration Participant Information\par \ulnone\b0 Please print clearly and fill out completely.\par \par Date Registered:_________________\par \par Child's Name:_______________________________________________ Date of Birth:_____________ M/F:_____\par \par Current School:___________________________________________________ Grade Entering Fall:__________\par \par Home Phone Number:____________________________ \par \par Home Address:_________________________________________________________________________________\par \par City:______________________________ State:_________________ Zip:___________________\par \par \par \b Parent Information:\par \par \b0 Mom's Name:_______________________________________ Mom's Employment:____________________________\par \par Mom's Work Number:_________________________________ Mom's Cell Number:____________________________\par \par Mom's E-mail Address:_________________________________________________________________________\par \par Dad's Name:________________________________________ Dad's Employment:____________________________\par \par Dad's Work Number:_________________________________ Dad's Cell Number:____________________________\par \b\par \b0 Dad's E-mail Address:__________________________________________________________________________\par \par \b Emergency Contact (in the event the parent cannot be reached):\par \b0\par Name:___________________________________ Phone Number:___________________ Relationship:_______________\par \par Medical Insurance Company:________________________________ Policy/Group #:_____________________________\par \par Please list any medical information, allergies, injuries, etc.:___________________________________________________\par \par I,___________________________________the parent/guardian of _______________________________________, give\par permission and hereby authorize Legion of Allstars, LLC and its employees to give consent for my child or myself to receive\par medical treatment in the event I cannot be reached or I am other wise unable to respond.\par \par \b Parent or Legal Guardian's Signature:___________________________________ Date:________________\b0\par \b ________________________________________________________________________________________\par Class Information\par \par \b0 Program:_________________________ Age/Grade:___________ Level:______________ Day:___________ Time:______\par \par ___________________________________________________________________________________________________\par \b Registration Fee, Due Date & Drop Information\par \b0\par \b Annual Registration Fee\b0 :..............................................................................$ 30.00\par \b Tuition is due at the first of every month.\par A $10.00 late fee will be added after the 10th of the month.\par A written notice is required one month in advance of withdrawal to director and no refunds are granted for\par the month during which a student withdraws.\par \par \par I understand and agree to comply with the Payment Due Date and Drop Procedure:\par \par \par Signature:______________________________________________ Date:_________________\b0\fs18\par \fs20\par \fs18\par \fs20\par \par \b\par \par \b0\f1\par }