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 2011]

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 $ 200 check payable to MIBG
Mail to - 267 Kentlands Blvd. P.O.Box 1062 Gaithersburg, MD 20878


Parents/Guardian Signature: _________________________________ Date: _______________