Application Form (Available to all Girls and Boys under 21)
Team Name:____________________________________________Age Div.:__________ A or B________
Responsible Person's Name:_______________________________________________________________
Address:_______________________________________________________________________________
City:___________________________________________State:______________Zip:__________________
Home Phone:__________________________________Cell ______________________________________
Email __________________________________________________________________________________
Signature:________________________________________________Date:__________________________
(This application must be signed) I certify that all information listed above is true and correct.
Combined Accident Medical Expense/Liability Coverage:
8 & under, 10 & under, 12 & under $110.00 per team
14 & under, 16 & under $140.00 per team
18 & under $190.00 per team
Official Roster Required. All participants may not have exceeded their 18th birthday as of January 1, 2012
Liability Coverage $2,000,000.00 Single Limit
Additional Insured for City or Park (not individuals): Name, Address, City, State, Zip and Fax
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
1st Additional Insured is free. Susbsequent Additional Insured: $25.00 Per Insured.
TOTAL OF ALL CHARGES ____________________ Coverage from January 1, 2012 thru December 1, 2012 at 12:01 am
Mail completed form, official roster, and your annual premium to:
American Fastpitch Association
2926 Calle Frontera
San Clemente, CA 92673
(949) 291-8783 - (949) 630-3340
