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Registration Form Fall 2010-Winter 2011 Basketball Academy ____ Session 1 Monday and Wednesday Start Sept 20th until Oct 13th 8 clinics____ Session 2 Monday and Wednesday Start Oct 25th until Nov 17th 8 clinics ____ Session 3 Monday and Wednesday Start Nov 29th until Dec 22th 8 clinics ____ Session 4 Monday and Wednesday Start Jan 3rd until Jan 26th 8
clinics Check One ________Lay-ups Grades Pre K-2nd grade ____ Bounce Passers Grades 3-5 Please Print: Players Name: _________________________________
Payment Information: Amount Charged: $ ________________ Card #: ____________________________________ Type( circle ) Visa Mastercard Discover Amex Billing Zip Code_______________ Name on Card: ____________________ Exp: __________ Cardholder Signature: ___________________ 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: _____________
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