Applicant: First Name / MI / Last Name

Date of Birth / Age


School / Grade 2007/2008



Male / Female


T-Shirt Size

Youth: small mediuml large
Adult: small medium large xlarge

Parent/Guardian: First Name / MI / Last Name


Street Address



City / State / Zip


Phone Number Home


Phone Number Work


Health Insurance Company

Group Number

Policy Number

Email Address

Liability Agreement
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I, the Parent/Guardian, agree my child is physically fit to participate in strenuous athletic activity, and waive 2XSALT, Inc., Football with the Pro’s, and its officers and employees of any and all responsibility for injury and illness. I hereby authorize the directors of 2XSALT to act for me according to their best judgment in any emergency requiring medical attention. I also understand that I am solely responsible for the payment of any medical expenses and must provide camp with proof of medical and accident insurance.

I Agree Initial


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Credit Card Information:

Visa: Master Card AMEX

First Name / MI / Last Name


Credit Card Number


Expiration Date / Security Code

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