Application

This application must be field out by all Participants in the video tournament.

All fields must be completed:

First Name: ___________________ _ M.I.: Last:

Address: _______________________________________________________

City: State: Zip Code: ________________ ______

Home Phone: (     )                Cell Phone: (___) _____________________

Email Address: Date of Birth: ___*

* Proof of age will be required

Under 18 you must have the Parental Consent Form signed

Under 12 you must be accompanied by an adult over 21 who is solely responsible for you the entire

event.

Emergency Contact Information (required when registering):

First Name: M.I.: Last: ______________________

Relationship to Participant: _________________________________________ __

Home Phone: (     )                Cell Phone: ___________________________

Signature: ______________________________ Date: ____________

(If you are under 18 the Parental Consent Form must also be completed for registration)

Applicant Number #: (for office use only)