I, (Parent or Guardian) agree, by enrolling my son/daughter that he/she is physically able to participate in all the clinic’s activities. In case of a medical emergency and I cannot be reached, I hereby give permission to the physician selected by staff to hospitalize and secure medical treatment for my child. I understand that my medical insurance is expected the cover of my child’s injuries. I agree not to hold Holy Name High School or the Basketball Specialists School responsible for any injury that may occur to my son/daughter while participating in the school. I also realize that the Holy Name High School is not sponsoring the school.
Parent Signature: Date: Medical Insurance: Policy #:
Tuition Enclosed: $
Please make checks payable to: Basketball Specialists
Adult T-Shirt Size: S M L XL
Please Mail To: Ilya Nicholas P.O. Box 573 Marlborough, MA 01752