21st CPA Elementary Basketball Summer Skills Clinic                          
21st Century Public Academy has organized a series of Elementary skill clinics for Basketball this summer. These clinics aim to help athletes develop their basic and advanced fundamental skills. Participants will be able to learn various skills such as basketball focus training, which includes fundamentals and drills, skill stations, fun games, small and large team competitions, and organized scrimmages.

Families will have the option to sign up for sessions of their athletes interest.

Summer Basketball Clinics (Co-Ed)
 -Thursday,    June 22, 2023  @  5:30-7:00p


Location:          21st Gymnasium: 4300 Cutler Ave

Grade Range:     Incoming 1-4th Grade (Public is welcomed)
                                 **LIMITED SPACES**

Event Fee:  $5 per athlete/per clinic (Registration fee due prior to event start)
                     **Cash, check, or Money Order (Payable to 21st CPA) 
                                
Registration Closes:  Child must be registered prior to participating in event. Registration fee due prior to athletes participation.

Event Description:
  • Walk- Up Registration (Day of Clinic) = If available

Proceeds from the clinics will benefit the 21st Century Public Academy Athletic Program.

For more information or details of events please contact: Dana "DA" Alexander at dalexander@21stcenturypa.com
Sign in to Google to save your progress. Learn more
Email *
Basketball Required Apparel and  Equipment:
Below is a suggested list of clothes, equipment, and personal items. 21st CPA Clinics are NOT responsible for lost or stolen articles or money.
-Water bottle (Name Labeled)
-Basketball Shoes (No black soles)
-T shirt and Athletic Shorts/Pants
-Medical Devices (Braces, Inhaler, etc.)
-Basketball (Optional) (Name Labeled)
Event
Mark each Elementary Basketball Skills Clinic your child will be attending?
Co-Ed Basketball
Thursday, June 22, 2023 @ 5:30-7p
Child's Information
Child's First Name: *
Child's Last Name: *
Child's Birth Date including year: (mm/dd/yyyy) *
Does your child have asthma? *
Does your child have any severe allergies to food or medications?
Leave the space "Blank" if this question does not relate to your child.
Does your child have any other important medication conditions we should know about?
Leave the space "Blank" if this question does not relate to your child.
Child's Grade in Fall 2023-2024:
Athletes Grade *
Is your child a current 21st Century Public Academy student? *
Parent's Information
First Name: *
Last Name: *
Home Phone: *
Cell Phone: *
Email Address: *
Relationship to child: *
Emergency Contact Information with Authorization to Pick Up:
List two individuals other than parent/legal guardian to be contacted in case of emergency; must be local and have permission to pick up your child.
1st Emergency Contact Name: *
Phone Number: *
2nd Emergency Contact Name: *
Phone Number: *
Waivers- (Required for participation)
21st Century Release Waiver:  Elementary Skills Clinic
21st CPA COVID- 19 Waiver Disclaimer
Parent(s)/ Guardian(s) acknowledge that they have carefully read the above Elementary Skills Clinic Release and COVID-19 Waiver Disclaimer and that they agree to its terms. *
Concussion In Sports (Fact Sheet)-  https://www.nmact.org/file/Facts_4_Families.pdf
Click the above web address (URL) to preview.
Parent(s)/ Guardian(s)  and student-athlete agree to the NMAA Concussion Fact Sheet for Athletes & Parents? *
I understand while participating in this activity, my (child/participant) may be photographed. I agree to allow my (child/participant) photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns. *
Type in your Full Name below:  Signature *
It is understood that you (Parent/Guardian) read and have agreed to all terms within the Release Waiver, COVID-19 Waiver,  Photo Release Waiver and Concussion Fact Sheet Document, by typing your full name in the space below.
Note:   There will be no refunds given once clinic, camps, or competitions starts.  There will be no refunds if a child becomes sick or injured during clinics, camps, or competitions.
Time and dates may/can change due to facility availability, weather, or unforeseen circumstances.  
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of 21st Century Public Academy. Report Abuse
Google Forms