Bollinger Lacrosse: Admin - AccountRequest

Your First Name: Your Last Name: Phone: Extension:	Organization Name: Address: Address 2: City: State: Zip Code:	Select Your User name: Password: Password Confirmation: Email Address: Email Address Confirmation:
I certify that the team or league for whom I am requesting this certificate mandates 100% membership in US Lacrosse, and that I have verified our team/league's roster and all participants are current members of US Lacrosse. I certify that this is true and I understand that a roster will be required in the event the event of a liability claim in order to confirm membership. I understand that liability claims will only be covered if the team carries 100% membership in US Lacrosse.