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AAU Tryouts Spring 2008 Wilkes-Barre Express Boys AAU Team Grade ____ Girls AAU Team Birth Year ____ Please Print Name: _________________________________ Street: _________________________________ City: _______________ State: ____ Zip: ______ Phone: ______________ Fax: ______________ Age: ______ Birth Date: _________ Grade: ___ E-Mail _________________________________ Position: _____ Height ______ Weight_______ School: ________________ Coach: __________ Group #: _____________Policy #: ___________ Payment Information: Amount Charged: $ ________________ Card #: ____________________________________Name on Card: ____________________ Exp: ____ Cardholder Signature: ___________________ Cost: $35 Billing Zip Code ____________ My child is in excellent physical health and capable of participating in strenuous physical activity, and waive BACKCOURT HOOPS of any and all responsibilities for injury or illness. I hereby authorize the director of BACKCOURT HOOPS to act for me according to their best judgment in any emergency requiring medical attention. I understand that I am solely responsible for the payment of any such medical expenses and must provide BACKCOURT HOOPS with proof of insurance. I also understand that my payments are non-refundable, non-transferable under any circumstances. Signature of Parent/Guardian _________________________________________ Date: _____________ Mail or Fax to: Scranton PA 18508 570-558-3833 fax 558-3835 Office use only: Amt pd. _________ Date Rec. ___________ Balance: ______________ |
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