Campers Name:     Street:  
City: State:     Zip: Phone:
cell:      Shirt Size: Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult Extra Large Adult XXL   Age:   Grade:    Gender Male Female
Birth Date:     E-Mail   School:

 Basketball Academy  $75 each Session   Boys & Girls

    Boys & Girls K thru 2nd Session 1      5:30pm Monday and Wednesday Start Sept 21st until Oct 17th  8 Clinics 
    Boys & Girls 3rd thru 5th Session 1    6:30pm Monday and Wednesday Start Sept 21st until Oct 17th    8 Clinics 

   Boys & Girls K thru 2nd Session 2      5:30pm Monday and Wednesday Start Oct 26th until Nov 21st 8 clinics (No Clinic Mon Oct 31 will be Tuesday Nov 1st)
    Boys & Girls 3rd thru 5th Session 2    6:30pm Monday and Wednesday Start Oct 26th until Nov 21st 8 clinics (No Clinic Mon Oct 31 will be Tuesday Nov 1st)  

    Boys & Girls K thru 2nd Session 3      5:30pm Monday and Wednesday Start Nov 28th until Dec 21st 8 clinics  
   Boys & Girls 3rd thru 5th Session 3    6:30pm Monday and Wednesday Start Nov 28th until Dec 21st 8 clinics

Boys & Girls K thru 2nd Session 4      5:30pm Monday and Wednesday Start  Jan 9th until Feb 1st 8 clinics
 Boys & Girls 3rd thru 5th Session 4    6:30pm Monday and Wednesday Start Jan 9th until Feb 1st 8 clinics

Boys & Girls K thru 2nd Session 5      5:30pm Monday and Wednesday Start Feb 13th until Mar 7th 8 Clinics  
Boys & Girls 3rd thru 5th Session 5    6:30pm Monday and Wednesday Feb 13th until Mar 7th 8 Clinics  

Total Amount for All Clinics registering

Health Insurance Co.      Group #: Policy #:
My child is in excellent physical health and capable of participating in strenuous physical activity, and waive Backcourt Hoops of any and all responsibilities for injury or illness. I hereby authorize the director of Backcourt Hoops to act for me according to their best judgment in any emergency requiring medical attention. I understand that I am solely responsible for the payment of any such medical expenses and must provide Backcourt Hoops with proof of insurance. I also understand that my payments are non-refundable, non-transferable under any circumstances.
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