REGISTRATION

_____________________________________________
NAME

___/____/______
BIRTHDATE

_____________________________________________
ADDRESS
CITY

_______
STATE

__________________________________
PHONE

______
AGE

____________
ZIP CODE

____________________________________
EMAIL

________________________________________________________________________
EMERGENCY CONTACT
RELATIONSHIP
PHONE #

SHIRT SIZE (circle one)

YOUTH:

ADULT:

XL

You can purchase extra shirts for $10 which a portion of the proceeds will go to local youth
foundation.
Individual ___ $20

*Team___$30

Additional shirts ___$10 x ___

*If registration is for a Team please fill out registration for each athlete.

REFUND POLICY
By signing you agree that you understand there are no refunds, transfers, or exchanges of
registrations for any reason.

PARENT/GAURDIAN
Send registration to:
St Charles Family Chiropractic
213 E 6th St
St Charles, MN 55972

DATE

Any question please contact 507-932-5696 or email stcharlesfamilychiro@gmail.com