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2. 
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Fax Number
16. Type of Program*
    -- Select One --PracticeGameLeagueEventOther
18. Type of Organization*
    -- Select One --Campbell County based Youth Organization (i.e. Dixie Youth Softball)Independent Youth Program (i.e. travel teams)IndividualSchool based programOther
20. Preferred Area(s) of the County*

    1. Concord
    2. Rustburg

    1. Timberlake
    2. Brookneal

    1. Altavista
    2. Other
22. Preferred Location(s)*

    1. Long Mountain Park
    2. Abbott Duncan Recreation Fields
    3. Timbrook Park

    1. Community Park
    2. Long Island Park
    3. Village Trail
24. Type of Facility*

    1. Soccer field
    2. Football field
    3. Softball field

    1. Baseball field
    2. Multipurpose field

    1. Disc golf course
    2. Trails

    1. Tennis courts
    2. Other
26. Do you require outdoor lights?*
    -- Select One --YesNoPreferred, but not required
28. Date Range*
    Date Range
29. Times*
    Times Start Time

    —

    Times End Time
31. Additional Information?
33. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
35. Electronic Signature
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field