2020 MLK Shootout Registration Form
**Registration Form Due: January 6, 2020**
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School Name *
Gender *
Age Group *
Level of Skill  [ 1  (low)  -  5  (high)  ] *
Coach Name: *
Head Coach Email Address: *
Head Coach Cell Phone: *
Coach Street Address: *
State *
Zip Code *
How did you hear about us? *
I am aware of the nature of this activity and I hereby assume all responsibility for my team to participate in this event.  I will not hold PBSA and/or their staff  responsible in the case of accident or injury as a result of this participation.  I understand that a completed consent form must be in the possession of PBSA (or their associates) prior to participating in this event. I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies, or video footage of the team named above by Preston Basketball Skills Academy (PBSA).  I also grant the right to PBSA to edit, use, and reuse said products for marketing purposes, including use in print, on the internet, and all the other forms of media.  All sales are FINAL.     *
Pakollinen
MLK Shootout Team Cost:
$125 - due 1/6/20
Payment Method *
(Select one)
Pakollinen
Credit Card Authorization Form
(A 3.75% service charge is added for credit transactions.)
Name on Card
Card Number
Expiration Date (MM/YY)
3 Digit Security Code
(on back of card)
Credit Card Billing Zip Code
I authorize Preston Basketball Skills Academy to charge my credit card for the Summer Basketball Clinics.  (A 3.75% transaction fee is added to credit card payments.)
Contact for Questions?
Please call Brooke Preston with questions at (330) 323-0806 or email at CoachBrookePreston@gmail.com.

For check or cash payments, please mail to:
Preston Basketball Skills Academy
P.O. Box 2074
Alliance, OH 44601
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