Please Print:

______Boys 4th-5th Grade ___6th-7th Grade ____ 7-8th Grade League

Girls Team League  _____4-5TH Grade ____ 5-6th Grade ____ 7-8th Grade

Team Name: ______________________ School _____________________  Coaches Name__________________________

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

Phone: ___________________ Cell Phone ________________________ Fax: ____________________
　　　　　

E-Mail _________________________________

2nd Contact Coaches Name__________________________

My players are 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 understand that we are 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 18512  Phone: (570) 558-3833 Fax: (570) 558-3835

Office use only:

Amt pd. _________ Date Rec. ___________ Balance: ______________