CT Northstars Individual Athlete
Registration Form

DATES:	September 12 - November 21, 2010
LOCATION:	Bulkeley High School
AGES:	5th grade - 11th grade
GAMES:	9 Game Gaurantee
BRACKETS:	“A” and “B”, schedule to be posted on the website
COST:	$100.00 per athlete / $50 per athlete
TOURNEY DIRECTORS	Ray DaCosta / Katie DaCosta P.O Box 340229 Hartford, CT. 06134-0229 (Office) 860-523-4888   (Fax) 860-432-3656

Please fill out the information below and click Submit Payment.
An asterisk (*) denotes a required field.

For a printable version click here.

Athlete Name:*
Assoc.:
Club Number:
Contact:*
Age:	Bracket: A B
Address:*
City:*
State:*	Zip:*
Cell Phone:
Home Phone:*
Work Phone:
Email:
Attended Last Year:	Yes No
Payment Amount:*
Credit Card:*	Visa Master Card
Credit Card Number:*
Expiration Date:*	01 02 03 04 05 06 07 08 09 10 11 12 2008 2009 2010 2011 2012 2013 2014