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

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Email Address for Confirmation of Submission (Required)

Online Basketball Program Cost

Your total payment will be