Youth Basketball Clinic Registration

Pay for the Youth Clinic Online!

Registration:  Now through March 20, 2010 - $75 (includes t-shirt, certificate and trophy)

Clinic Duration: March 20 – April 24, 2010

Age Divisions:   5-6 years

Contact: Mr. Morris at 313-541-9828 x 230

Required fields are marked with an asterisk*

Parent's Name:
Parent's Email Address:
First Participant's Name:
First Participant's Gender:	Male Female
First Participant's Age:
First Participant's Grade Level:
First Participant's Birthdate:
First Participant's School:
First Participant's Jersey Size (Youth):	Small Medium Large
Returning player?:	Yes No
Second Participant's Name:
Second Participant's Gender:	Male Female
Second Participant's Age:
Second Participant's Grade Level:
Second Participant's Birthdate:
Second Participant's School:
Second Participant's Jersey Size (youth):	Small Medium Large
Returning player?	Yes No
Street Address:
City:
Zip Code:
Parent's Contact Phone Numbers (home, work, cell):
Other Parent's Contact Phone Numbers (home, work, cell):
Does the participant have any allergies, dietary restrictions, or require any medications? Please indicate:
Name of physician:
Physician's Address:
Physician's Phone Number:
Insurance carrier and phone number:
Contact in Case of Emergency (if other than parents):
Emergency Contact's Phone Number: