BASKETBALL INSTRUCTION CLINICS REGISTRATION FORM

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					                     BASKETBALL INSTRUCTION & CLINICS REGISTRATION FORM
                                          One student athlete per registration form


NAME:                                                                                 DOB:

JERSEY SIZE:

ADDRESS:

CITY:                                                       STATE:                     ZIP:

SCHOOL:                                                                                GRADE:

MOTHER:                                                                PHONE #:

FATHER:                                                                PHONE #:

In case of an emergency, notify the following person if the parents can not be contacted.

NAME:

RELATIONSHIP:                                                          PHONE #:

I                                           authorize my son or daughter (circle one) to participate in the basketball

Instruction & Clinics for the dates of:                                                                        .

My son or daughter (circle one) has no medical problems that portability him or her from participating in Back2Basix

Basketball Camp; therefore I release Back2Basix from any liabilities.

                                                                             (Please print name)

I                                          understand my son or daughter (circle one) will be held accountable to the

Rules, regulations and the code of conduct required by Back2Basix. Any violations of these rules may result in

Suspension from Back2Basix Summer Basketball Camp without refund.
             BACK2BASIX SUMMER BASKETBALL CAMP - 704.488.9894 - back2basix@bellsouth.net