Mens Basketball League - Captain Registration

1
Team Role* This field is required.
Team Captain
Player
2
Team Name* This field is required.
3
Your Name* This field is required.
First Name
Last Name
4
Date of Birth* This field is required.
Date
Year
Month
Day
Date
5
Phone Number* This field is required.
Area Code
Phone Number
6
Email
example@example.com
7
What's your shirt size?* This field is required.
S
M
L
XL
2XL
3XL
4XL
8
Emergency Contact* This field is required.
First Name
Last Name
9
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
10
Rules & Regulations* This field is required.
11
Are you covered by personal/family insurance?* This field is required.
Yes
No
12
Name of Insurer
First Name
Last Name
13
Policy or Group #
14
Participation Waiver* This field is required.
15
Payment* This field is required.A $100 deposit is required to register your team. You can choose to make your entire registration payment now or pay the remaining $400 by check at the Coaches meeting.
My Bag
1
My Bag
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
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Registration Deposit
$100.00+
Back
Remaining Registration Fee
$300.00+Remove
Back
Total: $0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
16
Signature* This field is required.I agree that all information is correct, to the best of my knowledge. I understand that my $100 deposit is nonrefundable.
Should be Empty: