| Kozak Sports Center | ||||||
| 2005 League Registration | ||||||
| Town / State: | ||||||
| Club / Team: | ||||||
| Age / Genter Groupings: (check one) | Age Dates | |||||
| U9 Boys | August 1, 1995 - July 31, 1996 | U9 Girls | ||||
| U10 Boys | August 1, 1994 - July 31, 1995 | U10 Girls | ||||
| U11 Boys | August 1, 1993 - July 31, 1994 | U11 Girls | ||||
| U12 Boys | August 1, 1992 - July 31, 1993 | U12 Girls | ||||
| U13 Boys | August 1, 1991 - July 31, 1992 | U13 Girls | ||||
| U14 Boys | August 1, 1990 - July 31, 1991 | U14 Girls | ||||
| U15 Boys | August 1, 1989 - July 31, 1990 | U15 Girls | ||||
| U16 Boys | August 1, 1988 - July 31, 1989 | U16 Girls | ||||
| U17 Boys | August 1, 1987 - July 31, 1988 | U17 Girls | ||||
| U19 Boys / HS | August 1, 1986 - July 31, 1987 | U19 Girls / HS | ||||
| Mens Open | Womens Open | |||||
| Event | Format | FEE | Date of Event / First Game of League | |||
| 5v5 Futsal League | 10 games / 45 min | $950.00 | Week of January 3, 2005 | |||
| 7v7 Soccer League | 10 games / 45 min | $1,175.00 | Week of January 3, 2005 | |||
| Coach: | Coach Phone: | |||||
| Mgr/Contact: | Contact Nite Phone: | |||||
| Street: | Cotact Day Phone: | |||||
| City: | Contact Fax: | |||||
| State and Zip: | Contact E-mail: | |||||
| Contact Cell Phone: | ||||||
| Circle One: | ||||||
| Player Passes / Insurance Covering Each Player? | YES / NO | |||||
| Any Coments on level of play of team being entered: | ||||||
| Comments: | ||||||
| Coach / Manager Signature: (required) | ||||||
| Mail application with Check for Registration Fee, made payable to "Gene Kozak", and Send To: | GENE KOZAK 6 Middlebury Boulevard Randolph, NJ 07869 |
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| Tel: 973-927-1894 or E-mail: info@kozaksports.com | ||||||