Wembley Lacrosse Club - Perth Western Australia

2010 Winter Modcrosse and Junior Lacrosse

Registration Form

	ModcrosseU12 GirlsU13 Boys
Name :
Name of School :
Email Address :
Telephone Number :
Date of Birth :
Additional Comments :

Fees:
Modcrosse - $70
Under 12 Girls - $80
Under 13 Boys - $100

Payment Options: Cheques/Money Orders/Credit Card/EFT
Cheques payable to Wembley Lacrosse Club.
Post to Wembley Lacrosse Club PO Box 389 WEMBLEY 6014

EFT Payment Details:-
Westpac Bank BSB 036009 Account No167573
Account Name Wembley Lacrosse Club

Contact: Kevin on 0408 553 287