Registration Form | Basketball Specialists

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Application

Student Name:
Female                           Age:
School:
Grade:                                                   Email:
Address:
Phone #:

          I, (Parent or Guardian) agree, by enrolling my son/daughter that he/she is physically able to participate in all the clinic’s activities. In case of a medical emergency and I cannot be reached, I hereby give permission to the physician selected by staff to hospitalize and secure medical treatment for my child. I understand that my medical insurance is expected the cover of my child’s injuries. I agree not to hold Holy Name High School or the Basketball Specialists School responsible for any injury that may occur to my son/daughter while participating in the school. I also realize that the Holy Name High School is not sponsoring the school.

Parent Signature:
Date:
Medical Insurance:
Policy #:

Tuition Enclosed: $

Please make checks payable to: Basketball Specialists

Adult T-Shirt Size: S M L XL

Please Mail To:
Ilya Nicholas
P.O. Box 573
Marlborough, MA 01752