Registration
WestConn's Basketball Clinic with Head Coach Guy Rancourt
DATE: Saturday, March 30 OR Sunday, March 31
TIME: Grades: K-8: 10-12pm / Grades: 9-12: 1-3pm
ADDRESS: The O'Neill Center 43 Lake Ave Ext. Danbury, CT
CONTACT: guyrancourtbasketball@gmail.com
Date Attending *
Full Name
Your answer
Email *
Your answer
Home Address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender
Grade
School
Your answer
Emergency Contact (Name/Relationship/Phone)
Your answer
I certify that the applicant is in excellent physical health and is capable of participating in a strenuous activity, with basketball. I also agree to hold harmless the directors as stated above, Western Connecticut State University, it’s staff, agents, host site and employees from any and all injuries sustained by the participant during his/her participation. In case of emergency, I grant permission for the applicant to be given treatment at a local hospital. Any expense arising from injury or illness is the responsibility of parental insurance coverage. I have read and fully understand this release statement. *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service