Name:

Street Address:

Town:	Farmingdale	South Farmingdale
	Massapequa	North Massapequa
	Other  - please specify:

State: NY    ZIP Code:

Telephone:

Date of Birth: 

Month: select January February March April May June July August September October November December    Day: select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     Year: select 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 Pre 1952

Please Note: All players must be at least 40 (reached anytime during calendar year).   A proof-of-age & residency document will be required to establish player eligibility. Failure to provide documentation makes individual ineligible. Dates, times and location for providing documentation will be announced by the OTHG Board.

Email address:                                  

Be sure to enter your complete yourname@aol.com  or  yourname@optonline.net