Register

*Please use an Emergency Contact other than a parent.

Club dues for 2009/10 season are $550. Only half of the registration fees are due at this time. Mail your check payable to “CBC Lacrosse” to Dan Heaghney, 1057 Dougherty Lake Estates, St. Louis, MO 63122. Another meeting will be held in January for all players. The remaining dues will be collected at this time.

Questions???? Please contact Jerry Herber, Club President - jherber2@gmail.com

First Name

Last Name

Address

City

State

Zip

Home Phone Phone

Player Cell Phone

Cell Provider Provider

Player Email

Grade

Date of Birth

Father’s Name
N
Name

Work Phone

Father’s Email

Father Cell

Mother's Name

Work Phone

Mother’s Email

Mother Cell

Emergency*

Phone

Relationship

Cell

Did you play lacrosse last year?

If Yes, what team?

Years of lacrosse experience

Primary Position

Did you play goalie last year?

Jersey #

Shirt Size

Short Size

US Lacrosse Membership #

Parents, please one volunteer activity:

Last Year

Requested

*Required field -
Ctrl Click to choose more than one.

You will need your US Lacrosse Membership # to complete this form.
You can apply for this number by clicking this link US LACROSSE