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Registration: 2018 ROOKIE GIRLS (K-5)

K - 5th GRADE

USER INFORMATION
First Name:
Last Name:
Child's First Name:
Child's Last Name:
Age:
Gender:
Male  Female  
Grade:
Address:
Address 2:
City:
State:
Zip:
School:
Email:
Confirm Email:
Phone:
Cell:

CHOOSE 1 SESSION PER WEEK:
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JUNE 18-JUNE 28
8:00am-9:15am:
2 Week Discount All 8 days - $90  
View other options  
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JULY 9-JULY 19
8:00am-9:15am:
2 Week Discount All 8 days - $90  
View other options  
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JULY 23-JULY 26
8:00am-9:15am:
MON-THUR 4 day - $50  
NONE
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Registration form must be completed & payment must be made before any player and/or team participates in the Northern Michigan Basketball Academy Program.

There will be no refunds for unused sessions.

Waiver & release of all claims

Read this section carefully and be aware that in registering and participating you will be releasing all claims for injuries you might sustain out of this program.

As a participant in the program, I recognize and acknowledge that there are certain risks of physical injury and I agree the full risk of any injuries, including damages or loss which I may sustain as a result of participating in any and all activities connected with such program. I agree to waive and relinquish all claims that I may have as a result of my child's participation in the program. I further agree to indemnify and hold harmless and defend OrthoSport Physical Therapy and it's officers, agents, servants and employees from any and all claims resulting from injuries, including damage and losses sustained by me (or my child's immediate care) and agree that I will be responsible for payment of any and all medical services rendered. I HAVE READ AND FULLY UNDERSTAND THE ABOVE PROGRAM DETAILS AND WAIVER RELEASE OF ALL CLAIMS. Parent or guardian signature required for those under 18.

I have read and agree to the terms above.:
YES

Print Parent Name:
Parent Signature:
Emergency Contact:
Specific medical allergies, medicines or special needs:
Emergency Phone:
Date:
Enter the Security Code: