Mens Basketball League - Captain Registration

1
Team Role* This field is required
Team Captain
Player
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2
Team Name* This field is required
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3
Your Name* This field is required
First Name
Last Name
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4
Date of Birth* This field is required
Date
Year
Month
Day
Date
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5
Phone Number* This field is required
Area Code
Phone Number
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6
Email
example@example.com
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7
What's your shirt size?* This field is required
S
M
L
XL
2XL
3XL
4XL
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8
Emergency Contact* This field is required
First Name
Last Name
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9
Emergency Contact Phone Number* This field is required
Area Code
Phone Number
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10
Rules & Regulations* This field is required
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11
Are you covered by personal/family insurance?* This field is required
Yes
No
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12
Name of Insurer
First Name
Last Name
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13
Policy or Group #
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14
Participation Waiver* This field is required
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15
Payment* This field is requiredA $100 deposit is required to register your team. You can choose to make your entire registration payment now or pay the remaining $350 by check at the Coaches meeting on September 13th.
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Registration Deposit
$100.00+Remove
Back
Remaining Registration Fee
$350.00+Remove
Back
Total: $0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
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16
Signature* This field is requiredI agree that all information is correct, to the best of my knowledge. I understand that my $100 deposit is nonrefundable.
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Should be Empty: