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Youth Basketball Registration

Student Information

Student First Name*

Answer Required

Student Last Name*

Answer Required

Student Age*

Answer Required

Student Grade*

Answer Required

Mobile Phone

Answer Required

Street Address*

Answer Required

City*

Answer Required

Any health conditions we should know about in an emergency?

Answer Required

Parent's/ Guardian Information

First Name

Answer Required

Last Name

Answer Required

Email Address

Answer Required

Mobile Phone

Number Required

Emergency Contact Information

Please provide 2 emergency contacts

First Name

Answer Required

Last Name

Answer Required

Mobile Phone

Number Required

Relationship to student

Answer Required

First Name

Answer Required

Last Name

Answer Required

Mobile Phone

Number Required

Relationship to student

Answer Required

Confirmation Email

Email Required