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DOYLE
ENROLLMENT APPLICATION
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Must be completed to receive
Certification. Please print & complete all sections. Use one
application per coach.
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Last Name
__________________________________________________________
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York,
PA
Apr 17,
2010
$25 per coach
Mail
application & payment to:
Jason
Johnson
4855
Board Rd
Mt
Wolf, PA 17347
Make
checks payable to:
Doyle
BB
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First Name
__________________________________________________________
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Street Address
_______________________________________________________
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City _______________________________
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State ___________
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Zip __________
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Home Phone ( )
_______________________________________________
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E-Mail Address
________________________________________(for future updates)
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Occupation __________________________________________________________
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Age group that you coach
______________________________________________
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Have you previously attended Doyle Baseball? _______YES _______NO
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If YES, where
& when? _________________________________________________
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Would you be interested in becoming a Doyle Staff
Instructor: ___________________
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ACCIDENT INSURANCE INFORMATION - MUST BE COMPLETED TO
ATTEND THE PROGRAM - All coaches must provide proof of insurance
coverage for any injury or sickness while attending Doyle Baseball. I waive
and release Doyle Baseball from any injury or illness incurred going to
school from home or while at school or returning from school to home. I
hereby give my permission for emergency treatment in the event I cannot be
reached.
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PAYMENT INFORMATION
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Acceptance of Accident Insurance Disclaimer Above
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____Check
____Cash ____Visa ____MasterCard ____AmEx
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Name of Insurance Co.
_____________________________________
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Card Number ______________________________________Exp._____________
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Policy Number
____________________________________________
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Cardholder
Name____________________________________________________
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Student Signature
_________________________________________
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Signature__________________________________________________________
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