BASKETBALL INSTRUCTION & CLINICS REGISTRATION FORM
One student athlete per registration form
CITY: STATE: ZIP:
MOTHER: PHONE #:
FATHER: PHONE #:
In case of an emergency, notify the following person if the parents can not be contacted.
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 - email@example.com