Basketball Skills Clinic Registration
Email address *
Athlete's Name *
Your answer
Athlete's Division *
Your answer
Parent's Name *
Your answer
Parent's Cell Number #1 *
Your answer
Parent's Cell Number #2
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Emergency Contact Relation *
Your answer
Allergies (If none, type NONE): *
Your answer
Medication presently taking (If none, type NONE): *
Your answer
I grant permission to the director, assistants, or other persons responsible for his/her care to act on my behalf for said minor in granting permission for evaluation and treatment of medical problems. I understand that should a major medical problem rise, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I hereby give my consent to such treatment deemed necessary (including surgery, X-ray examinations and anesthesia to be rendered to said minor by a licensed physician, nurse). *
Required
Payment can be made in one $200 payment for all sessions or $25 per session. Payment will be paid through PayPal after completion of this application: *
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