Division I [Age 14 - 15] DOB after June 1, 1994 - Wednesday 9/1 - 7:00PM @ Quince Orchard HS
Division II [Age 12 - 13] DOB after June 1, 1996 - Thursday 9/2 - 6:30 @ Lakelands Park MS
Division III [Age 10 - 11] DOB after June 1, 1998 - Thursday 9/2 - 8:00 @ Lakelands Park MS


All participants are guaranteed a team roster spot.


APPLICATION


Applicant Name: __________________________________________ Date of Birth: ___________

Address: ______________________________________________________________________________

Parent's Email: _________________________________ Telephone: _________________________

Emergency Contact Name & Telephone #: ______________________________________________

Height: ______ Weight: _______ School: _________________________ Grade: _____ [Fall 2010]

I hereby grant permission for my child to attend the basketball program supported by Jr. NBA and its member MIBG. I understand that I am responsible for my child's insurance in case of injury. Furthermore, I understand that although safety precautions will be observed, Jr. NBA, MIBG, their employees and agents will not be responsible for any personal lost by my child or for any injury sustained in the program. I also consent to Jr. NBA and MIBG for the use of any photographs, CDs and video made of the program.


Please make $ 175 check payable to MIBG
Mail to -267 Kentlands Blvd. P.O.Box 1062 Gaithersburg, MD 20878


Please attach your business card for contact information.


Parents/Guardian Signature: _________________________________ Date: _______________