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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 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Registration Form Girls Fall 2008 Please Print: Name: _________________________________
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: _____________
Backcourt Hoops 5 West Olive Plaza Scranton PA 18508 fax 570-558-3835
Amt pd. _________ Date Rec. ___________ Balance: _____________ _
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