Player Name
_________________________________________________________________
Address__________________________________City________________State_____Zip_________
Player Home Phone:_______________________________________
Birthdate____________
Current
Grade______
#Years
Played______
School Attending_______________________ Medical
Problems?________________________
Parent/Guardian Name________________________________________ Work
#________________
Parent / Guardian Address__________________________ T-Shirt
Size XS
S M L
XL XXL
Phone _______________
Email_______________________ Referred By:_____________________
|
|
Please Circle one or more |
| 2010
Member of the BCWB Youth Summer Basketball League |
|
Non-Member of the
2010 BCWB Youth
Summer
Basketball League
|
| Individual Training |
Group Training (groups of 8 to 12) |
|
Individual Training |
Group Training (groups of 8 to 12) |
|
1/2
Hour Session
$35.00
Per Session |
1 Hour
Sessions
$25.00
Per Player |
|
1/2
Hour Session
$40.00
Per Session |
1 Hour
Sessions
$30.00
Per Player |
|
5 -
Half hours Sessions
$150 |
10 - 1
Hour Sessions
$200.00
Per Player |
|
5 -
Half hours Sessions
$175.00 |
10 - 1
Hour Sessions
$250.00
Per Player |
One-Time
Consultation session $50.00
If
you elect to purchase additional sessions, $35.00 of the Consultation
fee
will
be used as a credit for 5 Half hour or 10 One hour (group)
sessions.
|
Individual
session preference: M
T W TH (circle
one or more)
Group
Sessions: Tuesday's and Thursday's Evenings
Registration Instructions:
1) Fill out form completely
& legibly. Make
checks Payable to BCWB & mail to BCWB, SAQ, P. O. Box 3528, Fred. Md
21705
2) Parent/Guardian must read Medical Release, Code of
Conduct and
Parent/Guardian player permission.
Medical
Release,
Agreement to Abide by the Code of Conduct and Parent/Guardian player
permission
:
I certify that my child is in good physical condition and is fit to
participate
in BCWB SAQ Program; I have read and
understand the SAQ website. I agree, abide by, and
promote the
regulations and principles outlined. Additionally, I understand that my participation in
Basketball Coaches Without Boundaries activities involves risks and dangers of
serious
and permanent bodily injury. I, or my
parent/guardian,
if I am a minor, hereby release, hold harmless, discharge and agree not
to
sue BCWB, its Directors, Officers,
Employees,
Coaches, Officials, Volunteers, Agents, Sponsors, Advertisers,
Owners/Lessors
of Premises for any and all liability from my participation.
Date:
____________
Parent/Guardian Signature _________________________