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

Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

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

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Electronic Signature of Parent or Guardian (Required)

Date

Month

Day

Year

Email Address for Confirmation of Submission (Required)

Online Basketball Program Cost

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged