Indiana YHEC Registration Form

Please Print Clearly:

Last Name __________________________________________________________

First Name _____________________________________ M.I. _________________

Address____________________________________________________________

City ___________________________________State _______ Zip _____________

Phone (____)_______________________________________

Gender: ______ M or _______F

Birth Date: Mo.______ Day _______Year_________

Division: Jr. ____(under age 15) Sr._____(overage 14) (age on date of even)

Coached or sponsored by___________________________________________________________________

If team member, Team Name________________________________________________________________

My email address is (print very clearly)______________________________________________

Parent/Guardian Name_______________________________________________ (please print)

Parent/Guardian Signature____________________________________________

Date ____________________

RETURN THIS FORM AND $15.00 ENTRY FEE, WITH COPY OF BIRTH CERTIFICATE

AND HUNTER EDUCATION CERTIFICATION TO THE ADDRESS BELOW OR BRING WITH YOU ON THE DAY OF THE EVENT

MAIL COMPLETED FORM TO:

Indiana YHEC

6229 S. 1100 E.

Otterbein, IN 47970

Make check or money order payable to: Indiana YHEC

DO NOT SEND CASH