P.O. Box 191, Centreville, MD 21617

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Recreation Division Registrations Due by:	July 17, 2011
On-Time Registration Fees:	1 Child	2 Children	3 Children	4 Children
	$65	$110	$135	$155
Late Registration Fee:	Additional $10 per child on a space available basis only

Child #1 First Name:Last Name: Date of Birth: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008   Age:(prior to Sept. 1) Gender:FemaleMale Age Group: Co-ed 4 Co-ed 5-6 Co-ed 7-8 Co-ed 9-10 Girls 11-15 Boys 11-15  NOTE: 14 year olds may play if in 8th grade OR  in 9th grade and NOT playing high school soccer. Child #2 First Name:Last Name: Date of Birth: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008   Age:(prior to Sept. 1) Gender:FemaleMale Age Group: Co-ed 4 Co-ed 5-6 Co-ed 7-8 Co-ed 9-10 Girls 11-15 Boys 11-15  NOTE: 14 year olds may play if in 8th grade OR  in 9th grade and NOT playing high school soccer. Child #3 First Name:Last Name: Date of Birth: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008   Age:(prior to Sept. 1) Gender:FemaleMale Age Group: Co-ed 4 Co-ed 5-6 Co-ed 7-8 Co-ed 9-10 Girls 11-15 Boys 11-15  NOTE: 14 year olds may play if in 8th grade OR  in 9th grade and NOT playing high school soccer. Child #4 First Name:Last Name: Date of Birth: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008   Age:(prior to Sept. 1) Gender:FemaleMale Age Group: Co-ed 4 Co-ed 5-6 Co-ed 7-8 Co-ed 9-10 Girls 11-15 Boys 11-15  NOTE: 14 year olds may play if in 8th grade OR  in 9th grade and NOT playing high school soccer.

Parent Information First Name(s): Last Name: Best Phone #: Cell Home Office Email Address: Address: City: State: Zip: Preferred Home Field: -Select Field- Centreville Church Hill Roundtop Sudlersville Volunteer Interest (check all that apply): Team Mom Referee Board Member Coach Age Group:  -Select Age Group- Co-ed 4 Co-ed 5-6 Co-ed 7-8 Co-ed 9-10 Girls 11-15 Boys 11-15 Asst Coach  Age Group:  -Select Age Group- Co-ed 4 Co-ed 5-6 Co-ed 7-8 Co-ed 9-10 Girls 11-15 Boys 11-15 Team Sponsor Interest: $225/team - Please see Willy Agee Comments: