City…

                                                                City of Burbank                           FOR OFFICE USE ONLY:
Pullout Form                                 Park, Recreation, & Community Services Department
                                                        Sports Office - (818)238-5330
                                                                                                          Receipt #: _________
                                                                                                          AMT PD: __________

           200_ ROLLER HOCKEY LEAGUE REGISTRATION
             FALL WINTER SUMMER (Please circle one)
  Team Name _________________________________ Sponsor___________________________


  Team Captain __________________________ Address _______________________________


  City___________________ Zip ______ Hm. Ph. ________ Wk. Ph.. ________ Pgr __________


  email:__________________________________________                                   Fax#: _______________________
  Form of payment:                   CASH            CHECK (w/driver's lic.)                     VISA       MASTERCARD
                    Checks returned for lack of funds or credit card denied will disqualify the team from the program.

  Credit Card #: _________________________________________________ Exp: ____________
  Cardholder's Signature: ____________________________________________

  Please check all that apply:                                                    Registration Priorities:
                                                                                  Please check all that applies:
  [    ]   Returning Spring Team (NAME: ____________)
  [    ]   Returning Winter Team (NAME: _________)                                [ ] $1,095.00 - Adult Registration
  [    ]   Returning Fall Team (NAME: __________)                                                (includes 1 doz. Pucks)
  [    ]   New Team
                                                                                  $ 25.00 - USA-Inline Membership
                                                                                            (IF NOT 2005-05 MEMBER)

                                                                                  ____# Players x $25 = __________


  Please pick the night which best suits your team level of play. Fridays will be used for all leagues with more that six teams:

  [ ] MONDAY(PLATINUM)                [ ] TUESDAY(GOLD) [ ] WEDNESDAY(SILVER)                           [ ] THURSDAY(BRONZE)

  If necessary, what additional night will your team be available to play:

               [ ] MONDAY          [ ] TUESDAY           [ ] WEDNESDAY               [ ] THURSDAY           [ ] FRIDAY



                                        TEAM EVALUATION FORM
                                             (all teams please complete)
  PLEASE RATE YOUR TEAM TO ASSIST IN TEAM PLACEMENT.
  COMPETITIVE ATTITUDE ?
  CIRCLE ONE:             RECREATIONAL                  COMPETITIVE                         VERY COMPETITIVE
  OVERALL TEAM RATING?
  CIRCLE ONE:                         Beginner          Beg/Int          Intermediate       Advanced
  OTHER COMMENTS:




  TEAM MANAGER'S SIGNATURE:                                                              DATE:
   NOTE: Registration will be taken on a first come basis. No spots are reserved for returning teams.