Club Name: ________________________________________

Age Group:           11           12           13           14           15           16/17

Team Strength:           Natl Level Team           A           B+           B          
(Please circle and be honest to ensure top competition for all)

Coach's Name: ________________________________________

Contact Person: ________________________________________

Contact Phone: ________________________________________

Contact E-Mail: ________________________________________

Please send check for $425 to:

Liberty Belles
C\O Jill Cook
8400 Shore Front Pkwy #7E
Rockaway Beach, NY 11693

Make all checks payable to "Liberty Belles Events"