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Application

 

Student Name:                                                                           
Female                           Age:            
School:
Grade:                                                   Email:        
Address:  
Phone #: 
 

          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