| Player Information | |
|---|---|
| Player Name | Crew Bergen |
| Player's Date of Birth | 09/13/2018 |
| Do you have another player to register? | No |
| Do you have a player/coach that you would like to be on the same team with? | Yes |
| Please enter the players/coaches names | Team 1 - Legree |
| Player Registration | Player Registration, Qty: 1, Price: $250.00 |
| Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement | By submitting this I accept the terms of the aforementioned Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement. |
| Parent-Guardian Information | |
| Parent / Guardian Name | Carrie Bergen |
| Parent / Guardian Email | Email hidden; Javascript is required. |
| Parent / Guardian Cell Phone | 4025600880 |
| 2nd Parent / Guardian Name | Mitch Bergen |
| 2nd Parent / Guardian Email | Email hidden; Javascript is required. |
| 2nd Parent / Guardian Cell Phone | 4024292580 |
| Billing Address | 3009 S 26th Street Lincoln, Nebraska 68502 United States Map It |
| Total | $250.00 |
| Payment Method | PayPal Checkout |
By submitting this I accept the terms of the aforementioned Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement.