Backcourt Hoops
at Riverfront Sports Complex
5 West Olive Plaza Scranton PA 18508
570-558-3833   Fax  570- 558-3835
John Bucci   JBucci@backcourthoops.com
Jeff Fedak   
Jeff@backcourthoops.com

Mike Shields  MShields@backcourthoops.com
Amber Jacobs AJacobs@backcourthoops.com

  

Girls Fall League
Individual Signup
Tuesday Evenings 
Starting Sept 16th thru Oct 28th   Grades 9th thru 12th

Cost $70  Register early before league is filled
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Registration Form Girls Fall 2008

Please Print:  

Name: _________________________________


Street: _________________________________ City: ________________________ State: ____ Zip: ______


Phone: ______________ Fax: ______________ Cell: _______________________________


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


School: ________________ Coach ____________________ Coach Phone _______________________


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

Payment Information:

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 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.

Signature of Parent/Guardian _________________________________________ Date: _____________


Mail or Fax to:

Backcourt Hoops 5 West Olive Plaza Scranton PA 18508 fax 570-558-3835


Office use only:

Amt pd. _________ Date Rec. ___________ Balance: ______________

 





Girls AAU    nepaflames.com
Send mail to  hoops@backcourthoops.com  with questions or comments about our programs or facilities
570-558-3833
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Copyright © 2006 Backcourt Hoops    Last modified: 11/12/08

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