Youth Basketball Clinic Registration
Enter the participant and parent details, list any allergies or medical conditions, and complete the liability waiver and parent signature.
Participant's Name
*
First Name
Last Name
Participant's Age
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School Name
*
Allergies or Medical Conditions
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email Address
example@example.com
Send payment via Zelle or Apple Pay to 904-803-2315
Liability Waiver
I, as parent or legal guardian of the participant, hereby release The Rock Jax and Grace Lutheran from any liability for injuries or incidents that may occur during today's basketball clinic event.
Parent/Guardian Signature
*
Register
Register
Should be Empty: