ASA OF PA

16U, 18U B State Champ Entry

July 6, 7, 8, 2012

Complete all information and click on "Submit". Your information will be emailed to Jann Duck to be entered into the tournament.

Make check payable to "ASA of PA" for $450 and mail to: Jann Duck, 147 Middle Street, Centre Hall, PA 16828 within 7 days of submitting entry to make your entry official.

16U & 18U B State Championship Entry

Team Name*

Age Group *

Manager's Name *

First Name

Middle

Last Name

Manager's Address *

Address Line 1

Address Line 2

City

State

Postal Code

Home Phone*

Cell Phone*

Email Address*

Team's Home District or County*

NOTE: 2012 ASA Background Checks required for all adult members of team. At least 1 coach must have 2012 ACE Certification. Proof of clearance and/or completion must be presented at check-in.