Adaptive Sports New England & Franciscan Children's Youth Wheelchair Basketball Program
For athletes with a mobility impairment. Sundays, 2:30 - 4:30 at Ursuline Academy.
Athlete Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please describe your/your child's disability
*
Primary Parent/Guardian Name (if applicable)
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Email
*
example@example.com
Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Second Parent/Guardian or Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
*
example@example.com
Do you have your own sports chair?
*
Questions/comments/additional info
Submit
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