Pocono Heat Boys Fall League
Individual Signup
Wednesday and Sunday Evenings  Starting Sept 17th thru Oct 5th   Grades 9th thru 12^th

Cost $75  $140(Travel) $200(Travel +Showcase)

Register early before league is filled
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Registration Form Heat Boys Fall 2008
Please Print:  

Name: _________________________________     Circle One     VARSITY   or    JV

Street: ________________________ ___City: _____________________State: ____ Zip: ______

Phone: ______________ Fax: ______________ Cell: _______________________________

Age: ______ Birth Date: _________ Grade: ___ E-Mail _________________________________

School: ________________ Coach ____________________ Coach Phone __________________

Health Insurance Co. ______________________ Group #: _____________Policy #: ___________

Payment Information:

Make checks payable to Pocono Heat

Amount Charged: $ ________________ Card #: ____________________________________

Type( circle ) Visa Mastercard Discover Amex Billing Zip Code_______________

Name on Card: _________________ Exp: _____   Cardholder Signature: ___________________

My child is in excellent physical health and capable of participating in strenuous physical activity, and waive Backcourt Hoops & Pocono Heat of any and all responsibilities for injury or illness. I hereby authorize the director of Backcourt Hoops & Pocono Heat 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 & Pocono Heat with proof of insurance. I also understand that my payments are non-refundable, non-transferable under any circumstances.

Signature of Parent/Guardian _________________________________________ Date: _____________

Mail or Fax to:

Pocono Heat, PO Box, Tannersville, PA

Office use only:

Amt pd. _________ Date Rec. ___________ Balance: ______________