Jr. NBA - Application

Instructions:
Type your information into the following fields below. Upon completion, please click the PRINT button below to print out your application. Please sign, date, and mail your completed application and $200 check payable to MIBG to: 267 Kentlands Blvd., PO Box 1062, Gaithersburg, MD 20878.

Applicant Name:
Date of Birth:
Format example: 01/02/2012
Street Address:
City: ,  State:   Zip Code:
Parent's Email:
Telephone:
Emergency Contact Name:
Emergency Phone Number:
Height:
Weight:
School Grade:
(as of Fall 2014)
School Name:

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 videos made of the program.

Parents/Guardian Signature:________________________________________________________

Date:____________________________________