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 20th until Oct 13th 
    Boys & Girls 3rd thru 5th Session 1    6:30pm Monday and Wednesday Start Sept 20th until Oct 13th   

   Boys & Girls K thru 2nd Session 2      5:30pm Monday and Wednesday Start Oct 25th until Nov 17th   8 Clinics 
    Boys & Girls 3rd thru 5th Session 2    6:30pm Monday and Wednesday Start Oct 25th until Nov 17th   8 Clinics 

    Boys & Girls K thru 2nd Session 3      5:30pm Monday and Wednesday Start Nov 29th until Dec 22nd 8 Clinics 
    Boys & Girls 3rd thru 5th Session 3    6:30pm Monday and Wednesday Start Nov 29th until Dec 22nd 8 Clinics

Boys & Girls K thru 2nd Session 4      5:30pm Monday and Wednesday Start  Jan 3rd until Jan 26th 8 Clinics 
 Boys & Girls 3rd thru 5th Session 4    6:30pm Monday and Wednesday Start Jan 3rd until Jan 26th 8 Clinics 

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