Players Name:     Street:  
City: State:     Zip: Phone:
cell:         Age:   Grade:    Gender Female Male
Birth Date:     E-Mail   School:

Pre Registered & paid in Full Prices listed below

NO School Today 2010-10

   K1 Monday Oct. 11th 9am TO 12 $30

  K2 Friday Nov. 26th 9am TO 12 $30

  K3 M-W Dec 27th-29th 9am TO 12  $80

  K4 Monday Jan. 17th 9am TO 12 $30

K5 Friday Feb. 18th 9am TO 12 $30

B1 Monday Oct. 11th 9am to 12pm  $30

B2Tuesday Dec. 28th 9am to 12pm  $30

B3 Tuesday Dec. 28th 1pm to 4pm  $30

O1 Wed Dec. 29th 9am to 12pm  $30

O2 Wed Dec. 29th 1pm to 4pm  $30

O3 Monday Jan 17th 9am to 12pm $30

Total Amount for All  registering

Health Insurance Co.      Group #: Policy #:
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 By typing your name  you are giving an electronic signature Date:

Please PRINT  first

Allow 30 seconds after pressing submit. Please Know your total amount before  Pressing submit. this page does not give you a total