SMMJ Basketball Development Academy Clinic Enrollment Form

SMMJ Basketball Development Academy

Clinic Enrollment Form
I wish to enroll my child to:
- Thursday & Saturday Developmental Program -- $75
Name of Student:

First NameMiddle NameLast Name
Date of Birth:

MonthDayYear
Address of Student:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent Information
Full Name of Parent

First NameMiddle NameLast Name
Home Phone Number

Area CodePhone Number
Mobile Phone Number

Area CodePhone Number
E-mail
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Relation to the child:
•My child has been examined by a doctor within the past month. He/she has been found physicallyfit to complete in athletics.
•I will not hold SMMJ Sports Program, church, school, coaches or coordinators responsible for anyinjury resulting from an accident or any loss of valuables or equipment while playing or traveling toor from a game or practice session.
•SMMJ Sports Program insurance is considered secondary insurance.
•I will in no way interfere with the coaches, coordinators or game officials in their performance ofprogram duties.
I (parent/guardian) agree to terms of participation stated above.
Digital Signature of Parent/Guardian

First NameLast Name
THE REGISTRATION FEE MUST BE PAID AT TIME OF REGISTRATION
Should be Empty:

SMMJ Basketball Development Academy