2022 COED BASKETBALL CLINICS REGISTRATION FORM

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*Please Fill In All Information Completely; *PLEASE NOTE IF SESSION IS FULL, YOU WILL BE PLACED ON WAITING LIST. PLEASE CONTACT COACH FUSE @ (337) 551-9941 FOR ADDITIONAL INFORMATION. ONCE REGISTERED, BE ON THE LOOK OUT FOR AN EMAIL WITH A WELCOME LETTER.

Email *

CLINIC FLYER

STUDENT-ATHLETE FIRST & LAST NAME *

AGE GROUP *

6-9 YEARS OLD

10-13 YEARS OLD

14-17 YEARS OLD

STUDENT-ATHLETE'S CURRENT AGE *

(STUDENT-ATHLETE'S BIRTHDAY) DD/MM/YYYY *

YYYY

SESSION (I, II, III) *

WEEK 2 (JUNE 13, JUNE 14, JUNE 15) MON, TUES, WED (SESSION II) $50

WEEK 3 (JUNE 20, JUNE 21, JUNE 22) MON, TUES, WED (SESSION III) $50

MULTIPLE SESSIONS (II & III) (WEEKS 2 & 3) $100

PARENT 1/GUARDIAN FIRST & LAST NAME *

PARENT 1/GUARDIAN EMAIL *

PARENT 1/GUARDIAN PHONE NUMBER *

PARENT 2/GUARDIAN FIRST & LAST NAME

PARENT 2/GUARDIAN EMAIL

PARENT 2/GUARDIAN PHONE NUMBER

STUDENT-ATHLETE'S ADDRESS *

STUDENT-ATHLETE'S GENDER *

MALE (BOY)

FEMALE (GIRL)

DOES STUDENT-ATHLETE HAVE ANY LIMITATIONS OR MEDICAL CONDITIONS? *

Yes

DOES STUDENT-ATHLETE HAVE ANY LIMITATIONS OR MEDICAL CONDITIONS? *PLEASE EXPLAIN; IF NONE PUT N/A *

PAYMENT OPTIONS 1. PAYMENTS MUST BE RECEIVED IN FULL FOR REGISTRATION 2. *(ONLINE PAYMENTS ONLY) 3. NO CASH ACCEPTED) 4. TEXT (337) 551-9941 ONCE STUDENT-ATHLETE IS REGISTERED

1. CASH APP ($TheTeamFuseCamp), 2. VENMO (@FourthQuarterMentality, OR 3. ZELLE (3375519941)

PAYMENT METHODS

A copy of your responses will be emailed to the address you provided.

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