SWISH BASKETBALL PROGRAM
ONLINE REGISTRATION FORM

  Name(s)   Age(s)

Contact Name Contact Number
                                                                       
Email Address

How did you hear about us?  Select from the list Brochure Mailer Friend TV Radio Website-Internet Other   If a friend, who?

Program Type: Individual Instruction 

                        Pre-school Session 

                        Group Session    Select Day and Age Group Wednesdays 6p-7p age 5 - 7 Wednesdays 7p-8p age 8 - 9 Wednesdays 8p-9p age 10 - 12 Saturdays 9a-10a age 5 - 7 Saturdays 10a-11a age 5 - 7 Saturdays 11a-12p age 8 - 9

                        Summer Camp   Select Date and Age Aug 2 - 6 -- Age 5 - 7yrs -- 9am - 12pm July 12 - 16 -- Age 8 - 10yrs -- 9am - 3pm

                       
Please Select :         Beginner          Intermediate          Advanced

T-shirt Size (youth)       S        M        L

I,  give permission to
to participate in the SWISH Basketball Program.  I understand that Mark McDonnell, or any other staff member(s) are not responsible for an accident or injury that may occur while participating in this program.

                                                                       
                                                                                  Parent/Guardian Signature

 Please list any pertinent medical information of which we should have knowledge.

EMERGENCY INFORMATION

Name of Child 

Parent/Guardian 

Date of Birth  

Street Address

City         State          Zip 

Home Phone      Work Phone

Cell Phone

Name of Emergency Contact  Phone 

I give permission for my child to be taken to the hospital for emergency treatment when efforts to contact parent/guardian or emergency are unsuccessful. 

  
                     Parent/Guardian                           

Your registration will be confirmed via email.