Kids Ages 6-12 -Take the field at a Rockies weekend home game! Register for the Rockies Junior Starting Lineup® at any Colorado location during baseball season!



Your Name (*required)


Date of Birth*


Home Phone*

Parent's Work Phone*

Name of School*


Name of Parent or Responsible Adult*

How did you hear about the Comfort Dental/Rockies Junior Starting Lineup®?*
Radio Ad In-Office Rockies Game Program Coors Field Scoreboard TV Friend  Other*

If selected for Jr. Starting Lineup, does Comfort Dental have your permission to use your child’s name and/or likeness in its promotional materials? yes no 

Are you or any members of your family patients of Comfort Dental? yes no 

Do you have any special circumstances or needs we should be aware of?
yes no  If yes, please explain briefly

I certify that I am at least 18 years of age. I also certify that I or another responsible adult will accompany the above named child to Coors Field if he/she is selected to participate in the Rockies Junior Starting Lineup® promotion.