Saints Girls In-House Basketball

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Girls League Only Registration Form - Grades K - 8

PLAYER INFORMATION

* First Name:

* Last Name:

* Address:

* Birthdate:

* Gender:

* Grade:

* School:

* Shirt Size:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

* Parent, Guardian Email:

* Phone #:

PARENT/GUARDIAN #2 {Optional}*

Firstname:

Lastname:

Parent, Guardian E-mail:

Phone#:

* Policy #:

* Insurance Carrier:

WAIVER: I understand and accept the condition that neither Saints Girls Basketball, Mary Queen of Peace, facilities used, or anyone associated with this program assumes any responsibility for any accidents and/or medical, dental expenses incurred as a result of participation in this program. The applicant is in good health and able to participate fully with no restrictions. The applicant is covered by the insurance listed above.

I/we agree with the above *

Fee: $150.00 per player/$250.00 for 2 players/$325.00 for 3 or more players. Please make checks payable to Mary Queen of Peace. Form & payment may be mailed/dropped off to: Steve Burgholzer, 13 Lewis St., Medford, Ma. 02155

FOR LEAGUE USE ONLY:

Instructional Division _______ Junior Division __________

Intermediate Division _________ Senior Division _________

Amount $_______________________

Check # _________ Cash _________

Sibling: _____________________________

* indicates required fields

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Girls League Only Registration Form - Grades K - 8