LA DI State Registration

LA DI State Registration (submit this on-line form by Dec 11, 2015)

Fill out one form for each team. Before you submit each form, print the page for your school records and to submit with your check. Your State registration includes the cost of the State tournament, should you attend. The combined amount is $100 per team, made out to LA DI, due Saturday, January 23, 2016 to:
Nancy Farley
J.S. Clark Magnet School
1207 Washington Street
Monroe, LA 71201

* Indicates required field

School Name *

Age Level (Select One) *

Challenge Name (Select One) *

Team DI Membership Number *

Team Manager Name *

First

Last

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Cell Phone Number *

Work Phone Number *

Home Phone Number *

Fax Number *

Scheduling

Indicate below if you have a special scheduling request and write your request in the comments section. Requests may be made for the following reasons: Team Manager works with multiple teams (list team challenge names and membership numbers); Team member(s) on multiple teams (list team challenge names and membership numbers); distance.

Special Scheduling Request in Comments (Choose One) *

Yes No

Accomodations required (Mark all that apply) *

Comments (Do not include team members' names) *

Print this page prior to submitting. Required form entries are marked with an *

Submit