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| Name: | _______________________________ |
| E-mail: | _______________________________ |
| Address: | __________________________________________________________________ |
| City, St, Zip: | _________________________________________________ |
| Home Phone: | _______________________________ |
| School/Club: | _______________________________ |
| Head Coach Asst. Coach | |
| Shirt Size: | Adult Med. Adult Lg. Adult X-Lg. |
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Confirmations will be sent via email unless checked here: Checks should be made payable to: GAME FACE MANAGEMENT, LLC |
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Payment Information Clinic Fee: $125 Before - $150 After |
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Total Amount charged to credit card: _______________________________ Type: Visa MasterCard Check |
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Credit Card#: _______________________________ Exp. Date:_____________ |
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