Delaware Heat Girl's Basketball Club

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17U 1st Payment Deposit

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Email:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

The personal information collected is only used by Delaware Heat staff for the purposes defined at the time of the collection or use that compiles with those purposes. We do not share your information with any third parties. All information collected on this form is done so exclusively with your consent. The information on this form is true and complete to the best of my/our knowledge.

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1st Payment Deposit($600) *

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17U 1st Payment Deposit