Equipment Checkout Form

Equipment Checkout Form
Player Information
Player's Name*
Division (select one)*
Parent/Guardian Name*
Phone Number*
Email*
Address*
Equipment Rental Details and Credit Card Information

Equipment Rental Options

Helmet ($450 if not returned)

$450.00

Pads ($150 if not returned)

$150.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Authorization Terms

I authorize HB Chargers Youth Football & Cheer Program to charge my credit card for the following amounts if the rented equipment is not returned within 30 days after the end of the season:

- Helmet: $450
- Pads: $150
Signature*

Clear
Date

MonthDayYear
Should be Empty: