APPLICATION Applicant Name: __________________________ Date of Birth: _____________ Address: ___________________________________________________________ Parents' Email: _________________________________ Telephone: __________ Emergency Contact Name & Telephone #: _______________________________________________________________ Height: _______ Weight: ________ School: ________________ Grade: _______ I hereby grant permission for my child to attend the basketball program supported by 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, MIBG, its 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 MIBG for the use of any photographs and videotapes made of the program. Please make $165 check payable to MIBG - 267 Kentlands Blvd. P.O.Box 1062 Gaithersburg, MD 20878. Parents/Guardian interested in: Coaching: ___ Parents/Guardian Signature: _______________________________ Date: ______ please attach your business card for contact information.