John A. Danzi Athletic Center

Sunrise Highway South Service Road

Patchogue, NY 11772

$20 per/person Pre-Registration Required

$25 per/person Day of the Event

Name:

Address 1:

Address 2:

City:                                                        State:                         Zip:

Daytime Phone:                                       Evening/Cell Phone:

Email Address:

Pre-registration costs $20 per/person. If paying by credit card please enter your information below - your card will be charged $20 for the pre-registration. If paying by check please forward a check payable to LI2DAYBCW for $20 to:

LI2DAYBCW

P.O. Box 506

Nesconset, NY 11767

Payment Method:          Credit Card               Check

Name on Card:                                                         Card Type:

Card Number:

Expiration Date:                   /                                   Billing Zip Code:

Please Note: You will receive a confirmation email after submitting the form above. On the day of the event please check-in at the

"Pre-Registration" table. Thank you!

583 Montauk Highway

Eastport, NY

(631) 325-2955