Terre Haute Boys & Girls Club : Sports : Our Sports : Basketball Registration Form

Name

First Name

Last Name

Address

Country

Address Line 1

Address Line 2

City

State

Postal Code

Phone (Required)

Grade (Required)

Gender (Required)

School (Required)

Age (Required)

Shirt Size (Required)

Guardian

First Name

Last Name

Guardian Phone (Required)

Guardian Email (Required)

Would You Like To Coach (Required)

Coach Request (Will try to honor)

Medical Condition (Required)

Please explain Medical Condition

Electronic Signature of Parent or Guardian (Required)

Date

Email Address for Confirmation of Submission (Required)

Online Basketball Program Cost

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Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged