JAMZ 2017 HAYWARD SCHOOL CHEER & DANCE CAMP

Similar documents
JAMZ 2017 THOUSAND OAKS CHEER & DANCE CAMP

WELCOME TO STANLY COUNTY GYMNASTICS!

BIG ROCK GYMNASTICS & DYNAMITE CHEER

Before and After School Care

2003 AAU JUNIOR OLYMPIC GAMES DanceSport and Salsa ENTRY INSTRUCTIONS

The Clubs of Prestonwood Junior Golf Academy Summer Golf Camps 2016

Registration Form. Special Information (allergies, medical, behavioral, etc) you would like us to know about the gymnast/dancer:

CAPITAL BADMINTON ACADEMY.

Dance-Dance/Drill Team

2018 Jr. Celtics School Vacation Week Two Day Clinic Registration Packet

NSU PREVIEW DAY. Wednesday, March 28, :00 a.m. 6:00 p.m.

Miami Beach Rowing Club 2016 Summer Camp

Governors State University, College of Arts and Sciences Summer 2018 STEAM Camp Registration

Cheer Tumbling Registration Form. (Please complete all fields and understand all information stated below) Student Information

Metzlers Gymnastics Training Center NON-COMPETE TEAM REGISTRATION FORM Please Print Clearly

Athlete C hecklist. Step 1: Step 2: Step 3: Step 4: CONTACT INFORMATION:

Date of Birth Address City State Zip

Charter Oak Gymnastics Winter Camp 2016

Release of Liability PLEASE DO NOT CHANGE OR ALTER THE WORDING ON THIS WAIVER WITHOUT PRIOR APPROVAL FROM USROWING.

SUMMER YOUTH PROGRAMS 2018 PARTICIPATION INFORMATION FORM

Participant Information (Incomplete information will not be processed) Last Name First Name Male Female Date of Birth: / /

PARTICIPANT AGREEMENT (For Adult Participants) RELEASE OF LIABILITY, VOLUNTARY ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

Participant Information (Incomplete information will not be processed) Last Name First Name Male Female Date of Birth: / /

2017 WINTER BREAK CAMP REGISTRATION FORM

Welcome To The MasterDrive Experience. Driving Camp Application Package Instructions And Keys To Success

Personal Finance Summer Institute for College Readiness Application Instructions:

Summer Camp Application INTERNATIONAL DEVELOPMENT 101

Lake Washington Rowing Club

Membership Registration Form

Camper Information Camper Name: Age: DOB: Address: City: State: Zip: Parent Information Parent/Guardian Name: Home Phone: Cell: Parent s

Stars Vipers Prep Team

ANTEATER RECREATION SUMMER CAMP

HAWAII JUDO ACADEMY Building Champions for Success at All Levels in Life

Charter Oak Gymnastics Winter Camps 2018

Schedule: When: Saturday, December Time: 9:00-4:00pm Where: Garrett s Sports Complex/Fieldhouse Cost: $60/ per athlete

Looking for the Best Day Camp in South Florida? Look no further! CORAL REEF SPORTS CAMP Day Camp

Karen McCallum. Volunteer- Counselor in Training Applications. Spring Dear Counselor in Training Applicant:

POTOMAC VALLEY AAU REGISTRATION INFORMATION

U.S. GOLD GYMNASTICS & CHEER ACADEMY INC.

OBSERVED HOLIDAYS No classes

2016 Fall Soccer Coed 3-9 Years Old

Registration Form. Mother s/guardian Name: LAST FIRST INITIAL Address: Home Phone: City: State: Zip: Cell Phone:

Parent & Camper Handbook/Manual

Camp Braveheart Camper Registration

CITY KIDS DAY CAMP REGISTRATION FORM

Evaluation and Team Registration Information

All Star PREP Team Registration Form

2017/18 Out of School Program Registration Form

D.M.G. Athletics. The Official Indoor/Outdoor Summer Basketball League. Team Registration Packet

ESO GIRLS FASTPITCH SOFTBALL 2017 PLAYER REGISTRATION

After School Program Registration Form

2009 is the age they MUST compete at. If your athlete is 9 now but will be 10 in April, May, or June, they must compete in the 10 year old division.

I. Appendix B - Summer Camp Release and NCAA Compliance Attestation

Information about membership -

Personal Finance Summer Institute Application Instructions: Read all instructions carefully, incomplete applications will not be considered.

Community Advocacy and Mentorship Program s (CAMP) Life Skills Retreat

(Student Last name, First name Middle Initial).

RELEASE OF LIABILITY, PROMISE NOT TO SUE, ASSUMPTION OF RISK AND AGREEMENT TO PAY CLAIMS

2017 Horse Tails Summer Camp

NAU Volleyball Team Camp

Duc In Altum Days 2018 Registration

Bash Spirit. BASH Spirit Grand National April 21, 2018 Nova University. City State Zip City State Zip

YOUTH TRAPPER CAMP Join other youths aged 10 to 14 for a camp like no other!

The Roman Catholic Diocese of Charlotte

MEDICAL INFORMATION AND MEDICAL TREATMENT RELEASE AND AUTHORIZATION FORM

The Roman Catholic Diocese of Charlotte Office of Vocations

SUMMER CAMP ACKNOWLEDGEMENT OF RISK FORM

2017 Fall Soccer Coed 3-9 Years Old

DSN. CAMP [ERS] THINKING CREATIVELY

ORDER SONS OF ITALY IN AMERICA LODGE 2662 ARTS & CRAFTS VENDOR CONTRACT/RELEASE

2018 CYC Junior Rowing Summer Program Registration

MAKE WELLSTON BEAUTIFUL, INC

2017 ISLANDER SOUND WAVES June 5-9, 2017

SUMMER CAMP AT MATRIX GYMNASTICS

Instructions for Completing Ford DSFL Waivers

Session I and Session II Session I: June 5 June 9, Performance June 10th; Hollydale United Methodist Church

Enviro-Quest 2016 camp information

Pocock Rowing Center

Athletics Participation and Pre-Participation Head Injury/Concussion Reporting Form

Texas Southern University Ocean Of Soul Marching Band. Summer Band, Auxiliaries, and Drum Major Camp Sunday, June 18 th to Saturday, June 24 th, 2017

Continuing Education Discovery College Registration Form

2018 Youth Academy Parent/ Guardian Agreement with NUS s Continuing Education

The Clubs of Prestonwood J.G.A. Summer Academy 2018

Florida Waiver (Commercial) (All parents of minors who are Florida residents must sign both the Florida commercial and non-commercial waivers)

FOR THE LOVE OF LEARNING 3110 SE Aster Lane, Stuart, FL

Only 200 kids are permitted to attend a clinic, and there must be a minimum of 75 participants.

PAL ADVANCED GOLF CAMP

Individual waiver Form: Master form included, makes copies as needed. Athletes should sign only where indicated (at ATHELTE S SIGNATURE line).

Track & Field Camp TRACK & FIELD WINTER. Elizabeth Krug Assistant Track & Field Coach. Camp Counselors Current SNC Athletes

BE A PART OF SOMETHING GREATER Membership Application BRAD AKINS BRANCH

HELPING TEENS THRIVE. Youth & Government CENTRAL YMCA

Somervell County Horse Camp

2016 OUCI Chinese Bridge Summer Camp Application

2017 Clinic Boys 8-12

ADULT LEARN TO SAIL PROGRAM

ATHENS YMCA CAMP KELLEY SUMMER CAMP 2018

TULANE UNIVERSITY ATHLETICS CAMPS Physical Examination Information. Date / / Name of Camp: Name of Participant: Age: Birth date: / /

MCC Summer Camp Application

North Carolina A&T Summer Youth Programs Let the summer fun begin!

The Towers Fitness Center Agreement and Waiver of Liability. Name: Company: Address: Building # Suite #

Transcription:

JAMZ 07 HAYWARD SCHOOL CHEER & DANCE CAMP EVENT DETAILS WHEN: Tuesday, July th - Thursday, July 7th CAMP SCHEDULE: Coach Check-in: 9:00am (Tuesday) Camp Instruction: :00am - 9:00pm (Tuesday) 9:00am - 9:00pm (Wednesday) 9:00am - :00pm (Thursday) Camp Showcase: :pm - :00pm (Thursday) *LUNCH & DINNER Breaks In-Between* WHERE: CSU, East Bay 800 Carlos Bee Blvd Hayward, CA 9 WHAT TO BRING Water Bottle Sunscreen Spending Cash for Camp T-Shirts, Shorts & Fun Stuff Comfortable Athletic Shoes Form-Fitting Athletic Clothing (loose/baggy clothes are a stunt safety hazard) Crazy Night Theme: School Spirit - It s homecoming week at JAMZ and we want to see how much school spirit YOU VE got! Dress to impress, and get as crazy as you can in your school colors! Overnight Participants: Bring bedding (sleeping bag/blankets, pillow), towel, alarm clock, toiletries. Overnight teams require coach per every 0 participants. Males and females will stay in seperate room accommodations. Due to campus layout and set room blocks, team/squad rooms may be seperated. COST: Overnight: $0.00 Per Overnight Participant $80.00 Per Overnight Coach ( FREE Overnight coach per every 0 Overnight Participants) Commuter: $00.00 Per Commuter Participant $0.00 Per Commuter Coach WHAT S INCLUDED Overnight: All meals, housing accommodations, camp instruction Commuter: Lunch & Dinner Meals Pyramid & Basket Toss Classes Creative Stunt Classes Home Routines - Day One (Optional) Friday Night Lights Material Bid Routine Challenge Team Bonding Activities Dance Team Instruction/Specialty Classes HOW TO REGISTER ) Complete the following forms (see additional pages): Team Registration Form Team Agreement of Compliance Form. Jr. Coach/Underage Coach Agreement of Compliance Form ) Submit all forms at the same time and one team payment using an option below: Option : Mail Checks (no personal checks) and all required forms to: JAMZ Summer Camps P.O. Box 08, Modesto, CA 9 Option : Fax all required forms and credit card form to 09-78-7. Option : Email all required forms and credit card form to registration@jamz.com. Camp tuition and registration are due in the JAMZ Office by: Monday, June, 07 Payment must be received with registration forms. Money must be paid in full by due date to guarantee space overnight. QUESTIONS? Call us or email registration@jamz.com.

TEAM REGISTRATION FORM 07 HAYWARD JAMZ SCHOOL CAMP MAIL this form (with payment) to: JAMZ SUMMER CAMPS: P.O. BOX 08, MODESTO, CA 9, EMAIL forms to registration@jamz.com or FAX forms to: (09) 78-7. ALL REGISTRATION & PAYMENT DUE: Monday, June, 07. REMINDER: Agreement of Compliance Forms are required to participate at camp. Forms can be mailed, faxed, or turned in at coach check-in prior to the start of the first day of camp. Camp Location: CSU East Bay, 800 Carlos Bee Blvd. Hayward, CA 9 Camp Dates: July -7, 07 Team/Organization: Level: (i.e. Middle School, Freshman, Junior Varsity, Varisty) Team Type (check only one box): Cheer Team Dance Only (no stunt) All correspondence will be forwarded to the contact person listed below: Coach s/coordinator s/advisor s First Name Last Name: Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Email Address: Additional Contact Person: Phone: ( ) Please complete the fields below. Names of individuals participating are required. Make additional copies as needed. PARTICIPANT NAMES FIRST NAME LAST NAME 7 8 9 0 7 8 9 0 PARTICIPANT TYPE Female Male My signature below indicates that I have read and agree with JAMZ Policies and Procedures. I am responsible for communicating this info to my coaching staff, parents and participants. Signature: Total # of Overnight Participants: multiplied by $ 0.00 (Tuition per Participant) = $ Total # of Coaches: Total # of PAID Overnight Coaches: multiplied by $ 80.00 (Tuition per Participant) = $ Total # of Commuter Participants: multiplied by $ 00.00 (Tuition per Participant) = $ Total # of Commuter Coaches: multiplied by $ 0.00 (Tuition per Participant) = $ TOTAL PARTICIPANTS = TOTAL AMOUNT = $ FOR OFFICE USE ONLY: DR DE MOP IP CFM

TEAM AGREEMENT OF COMPLIANCE FORM CSU EAST BAY, HAYWARD JAMZ SCHOOL CAMP Medical Treatment, Liability Release, & Appearance Agreement for JAMZ American Spirit Connection, Inc. ORGANIZATION/TEAM NAME: MAIN CONTACT: DATE SUBMITTED: SIGNATURE: A. As the parent or legal guardian of the above-listed child, I freely acknowledge that I have voluntarily registered my child to participate in cheerleading activities of JAMZ AMERICAN SPIRIT CONNECTION, INC., a California corporation (hereinafter JAMZ ), which include dance, gymnastics, stunting, jumping and tumbling components. I acknowledge that my child s participation in the JAMZ cheerleading activities entails both known and unanticipated risks that could result in serious and permanent physical and emotional injuries to my child, my child s death, damage to property, and injury tthers. I understand that such risks are inherent in the activities and that even with precautions and safety measures they simply cannot be eliminated without jeopardizing the essential qualities of the activities. I also understand and acknowledge that injuries received by my child may be compounded or increased by negligent rescue operations or the assistance of JAMZ Representatives (defined below). Understanding such dangers, I hereby knowingly and voluntarily enroll my child in the JAMZ cheerleading event, I give my permission for my child to engage in the activities described herein, and I assume the risk of the activities involving my child. I understand that my child would not have permission to participate in the JAMZ cheerleading activities without agreeing to these terms and conditions. B. I represent that my child is in good health, that I adequately informed JAMZ Representatives running the activities of any special instructions regarding my child s health or physical condition. I certify that I have adequate insurance to cover any injury or damage that my child may suffer while participating in the JAMZ cheerleading activities. I agree to bear the costs of any injury or damages my child may suffer while participating in the JAMZ cheerleading activities. I hereby authorize JAMZ Representatives to call for medical care for my child or to transport my child to a medical facility or hospital if in the opinion of such personnel, my child needs medical attention. I hereby authorize and grant permission to emergency medical personnel to administer first aid or immediate medical treatment to my child should my child become injured or ill. C. On behalf of my child and myself, I hereby knowingly and voluntarily release and forever discharge JAMZ or its employees, agents, coaches, instructors, assistants, officers, directors, owners, shareholders, subcontractors, and any other representatives or affiliates and their respective heirs, successors, and assigns (collectively with JAMZ, JAMZ Representatives ) from any and all liability arising out of or in connection with the above-described activities involving my child. Liability means any and all claims, demands, losses, causes of action, lawsuits or judgments of any and every kind that occurs during or incidental to the above-described activities, that results from any cause whether caused by the negligence of the JAMZ Representatives or otherwise. D. I hereby agree to and shall indemnify, defend, save and hold harmless JAMZ Representatives from and against any and all loss, liability, damage, or cost JAMZ Representatives may incur, including attorneys fees and litigation costs, arising out of or related to the above-described activities, whether caused by the negligence of JAMZ Representatives or otherwise. E. I hereby agree that the assumption of risk, the release and waiver of liability, and the indemnity agreements contained herein extend to all acts of negligence by JAMZ Representatives including negligent rescue operations, is intended to be as broad and inclusive as is permitted by the laws of California and any other state whose laws apply to the activities described herein, and that if any portion of this form is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. F. I give JAMZ Representatives the right to photograph or video tape my child, or likeness of my child, for any reproductions associated or in any way connected with any televised or filmed event undertaken by JAMZ. Specifically, I hereby forever and irrevocably grant to JAMZ a license and permission to use any such photographic or video reproduction of my child in any form of advertisement for JAMZ or its promotional purposes. G. By signing this form I represent that I have read this form thoroughly and understand it completely, including the substantial legal rights I am giving up for my child and myself by signing it. I have had the opportunity to have my own attorney review this form and my attorney has done sr I have knowingly and voluntarily chosen not to have my attorney review this form. I have signed this form freely and voluntarily without inducement of any kind or guarantee being made by JAMZ Representatives or anyone else. I intend by my signature for this form to be a complete and unconditional release of any and all liability to the greatest extent allowed by law. I understand and agree that this form cannot be amended or modified by any oral statements or other writings from any JAMZ Representatives and that it is binding on my child, myself, and our heirs, successors, distributees, guardians, legal representatives, and assigns. This form is valid for any JAMZ event conducted from 0//07-09/0/07. This form MUST be filled out completely. Please photocopy this form and retain for your records. This form is not valid for JAMZ Championship Events. Fax this form to JAMZ Registration Department 09-78-7 or Mail to JAMZ Summer Camps: PO Box 08, Modesto, CA 9. PARTICIPANT NAME DOB M / F Insurance Company Name Parent/Legal Guardian Signature Date Signed Cell # / Emergency Contact EX. Stephanie Smith 0/0/9 F Blue Cross MIKE Smith //7 () -/Mike Smith 7 8 9 0 7 8 9 0 If you have more than 0 participants in your organization/team, please duplicate this form as necessary.

JUNIOR COACH/UNDERAGE COACH AGREEMENT OF COMPLIANCE FORM CSU EAST BAY, HAYWARD JAMZ SCHOOL CAMP Medical Treatment, Liability Release, & Appearance Agreement for JAMZ American Spirit Connection, Inc. JAMZ REQUIRES EVERY COACH, JUNIOR COACH, TRAINER, ETC. UNDER THE AGE OF 8 PARTICIPATING AND/OR ATTENDING CAMP TO HAVE A PARENT/GUARDIAN SIGNATURE. Have each coach, junior coach, trainer fill out their information in the spaces provided below with a parent/guardian signature. EACH coach under the age of 8 must have a parent/guardian signature in order to participate/attend camp. ORGANIZATION/TEAM NAME: MAIN CONTACT: DATE SUBMITTED: SIGNATURE: A. As the parent or legal guardian of the above-listed child, I freely acknowledge that I have voluntarily registered my child to participate in cheerleading activities of JAMZ AMERICAN SPIRIT CONNECTION, INC., a California corporation (hereinafter JAMZ ), which include dance, gymnastics, stunting, jumping and tumbling components. I acknowledge that my child s participation in the JAMZ cheerleading activities entails both known and unanticipated risks that could result in serious and permanent physical and emotional injuries to my child, my child s death, damage to property, and injury tthers. I understand that such risks are inherent in the activities and that even with precautions and safety measures they simply cannot be eliminated without jeopardizing the essential qualities of the activities. I also understand and acknowledge that injuries received by my child may be compounded or increased by negligent rescue operations or the assistance of JAMZ Representatives (defined below). Understanding such dangers, I hereby knowingly and voluntarily enroll my child in the JAMZ cheerleading event, I give my permission for my child to engage in the activities described herein, and I assume the risk of the activities involving my child. I understand that my child would not have permission to participate in the JAMZ cheerleading activities without agreeing to these terms and conditions. B. I represent that my child is in good health, that I adequately informed JAMZ Representatives running the activities of any special instructions regarding my child s health or physical condition. I certify that I have adequate insurance to cover any injury or damage that my child may suffer while participating in the JAMZ cheerleading activities. I agree to bear the costs of any injury or damages my child may suffer while participating in the JAMZ cheerleading activities. I hereby authorize JAMZ Representatives to call for medical care for my child or to transport my child to a medical facility or hospital if in the opinion of such personnel, my child needs medical attention. I hereby authorize and grant permission to emergency medical personnel to administer first aid or immediate medical treatment to my child should my child become injured or ill. C. On behalf of my child and myself, I hereby knowingly and voluntarily release and forever discharge JAMZ or its employees, agents, coaches, instructors, assistants, officers, directors, owners, shareholders, subcontractors, and any other representatives or affiliates and their respective heirs, successors, and assigns (collectively with JAMZ, JAMZ Representatives ) from any and all liability arising out of or in connection with the above-described activities involving my child. Liability means any and all claims, demands, losses, causes of action, lawsuits or judgments of any and every kind that occurs during or incidental to the above-described activities, that results from any cause whether caused by the negligence of the JAMZ Representatives or otherwise. D. I hereby agree to and shall indemnify, defend, save and hold harmless JAMZ Representatives from and against any and all loss, liability, damage, or cost JAMZ Representatives may incur, including attorneys fees and litigation costs, arising out of or related to the above-described activities, whether caused by the negligence of JAMZ Representatives or otherwise. E. I hereby agree that the assumption of risk, the release and waiver of liability, and the indemnity agreements contained herein extend to all acts of negligence by JAMZ Representatives including negligent rescue operations, is intended to be as broad and inclusive as is permitted by the laws of California and any other state whose laws apply to the activities described herein, and that if any portion of this form is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. F. I give JAMZ Representatives the right to photograph or video tape my child, or likeness of my child, for any reproductions associated or in any way connected with any televised or filmed event undertaken by JAMZ. Specifically, I hereby forever and irrevocably grant to JAMZ a license and permission to use any such photographic or video reproduction of my child in any form of advertisement for JAMZ or its promotional purposes. G. By signing this form I represent that I have read this form thoroughly and understand it completely, including the substantial legal rights I am giving up for my child and myself by signing it. I have had the opportunity to have my own attorney review this form and my attorney has done sr I have knowingly and voluntarily chosen not to have my attorney review this form. I have signed this form freely and voluntarily without inducement of any kind or guarantee being made by JAMZ Representatives or anyone else. I intend by my signature for this form to be a complete and unconditional release of any and all liability to the greatest extent allowed by law. I understand and agree that this form cannot be amended or modified by any oral statements or other writings from any JAMZ Representatives and that it is binding on my child, myself, and our heirs, successors, distributees, guardians, legal representatives, and assigns. \ This form is valid for any JAMZ event conducted from 0//07-09/0/07. This form MUST be filled out completely. Please photocopy this form and retain for your records. This form is not valid for JAMZ Championship Events. Fax this form to JAMZ Registration Department 09-78-7 or Mail to JAMZ Summer Camps: PO Box 08, Modesto, CA 9. JUNIOR COACH NAME DOB M / F Insurance Company Name Parent/Legal Guardian Signature Date Signed Cell # / Emergency Contact EX. Stephanie Smith 0/0/9 F Blue Cross MIKE Smith //7 () -/Mike Smith If you have more than underage coaches in your organization/team, please duplicate this form as necessary.

CREDIT CARD/E-CHECK AUTHORIZATION FORM 07 CSU EAST BAY JAMZ SCHOOL CAMP INSTRUCTIONS: ) Choose which payment method you prefer and complete all info requested. ) MAIL forms to: JAMZ SUMMER CAMPS: PO BOX 08 MODESTO, CA 9 or FAX forms to: (09) 78-7. ) Camp Registration and Payment are due to the JAMZ Office by: Monday, June, 07 Team/Organization/School: Camp Location: CSU, EAST BAY. 800 CARLOS BEE BLVD. HAYWARD CA 9 Camp Date: July -7, 07 PLEASE PRINT LEGIBLY OR TYPE: I,, here by authorize the following charges: PRINT NAME Total Number of OVERNIGHT Participants: X Fee Per Participant: $ 0.00 = Total Number of OVERNIGHT Coaches: X Fee Per Participant: $ 80.00 = Total Number of COMMUTER Participants: X Fee Per Participant: $ 00.00 = Total Number of COMMUTER Coaches: X Fee Per Participant: $ 0.00 = **NEW** Total Number of Parking Passes: X # of Days X Fee Per DAY: $.00 = (I.E. PASSES: X # OF DAYS X FEE PER DAY: $.00 = $.00) TOTAL AMOUNT TO BE CHARGED $ PAYMENT OPTION - CREDIT CARD INFORMATION IF USING A CREDIT CARD, PLEASE CHECK ONE: VISA MASTER CARD AMERICAN EXPRESS DISCOVER Name as it appears on Credit Card: PRINT NAME Expiration Date: / Credit Card Security Code: Billing ZIP Code: MONTH YEAR / / ( ) SIGNATURE OF CARD HOLDER DATE CONTACT NUMBER Please write each digit of the Credit Card Number in the blocks provided below: PAYMENT OPTION - E-CHECK INFORMATION I AUTHORIZE JAMZ TO INITIATE EITHER AN ELECTRONIC DEBIT OR TO CREATE AND PROCESS A DEMAND DRAFT AGAINST MY BANK ACCOUNT ON OR AFTER THE DATE SUBMITTED FOR THE AMOUNT OF THE TOTAL CHARGE SHOWN ABOVE. I ACKNOWLEDGE THAT THE ORIGINATION OF ACH TRANSACTIONS TO MY ACCOUNT MUST COMPLY WITH THE PROVISIONING OF UNITED STATES LA LAW. AN NSF CHECK WILL RESULT IN AN AUTOMATIC DRAFT ON MY ACCOUNT FOR A $ NSF FEE. MY ACCOUNT INFORMATION IS AS FOLLOWS: W. AN NSF CHECK WILL RESULT IN AN AUTOMATIC DRAFT ON MY ACCOUNT FOR A $ NSF FEE. MY ACCOUNT INFORMATION IS AS FOLLOWS: Name as it appears on Check: (TEAM, ORGANIZATION OR LEAGUE NAME ON CHECK) Routing Number: Account Number: / / ( ) SIGNATURE OF ACCOUNT HOLDER DATE CONTACT NUMBER FOR OFFICE USE ONLY: DR DE IP CFM