Riverside Basketball Association
Riverside Basketball Assoc. 2479 Westminster Blvd., Windsor, ON, N8T 1X9
Phone: 519.257.0304, riversidefalconsbasketball.com
*Please not ALL PLAYERS MUST BE REGISTERED ON-LINE AT
http://riversidefalconsbasketball.com/site/
*Personal Information:
First Name: _____________________________________
Last Name _____________________________________
Date of Birth:
_____________________________________ (mm/dd/yyyy)
Address:
# Street:
City:
Postal:
__________________________________________
__________________________________________
________ _____________
2016-17
Registration
$500.00
Final Payment
$ _____________
Cheque / Cash
Down payment
$ _________
Credit Card
$150.00
Paid
Un-paid
$___
$__
Uniform Fee
$150.00
(to be refunded upon
return of uniform)
Home Phone #
Cell Phone #
_________________________
_________________________ Work Phone #: ______________________
e-Mail Address:
______________________________________________
Emergency Contact Name:
____________________________________
Emergency Contact #:
____________________________________
* Parents Information:
Father’s Name
Phone #:
Home:
& e-mail:
_____________________________________________
____________ Cell:
_______________ Work: ______________
____________________________________
Mother’s Name
Phone #:
Home:
& e-mail:
_____________________________________________
____________ Cell:
_______________ Work: ______________
____________________________________
*Health Information
 HEALTH Card #:
____________________________________
 Allergies:
____________________________________
 Other Medical Information
Riverside Sports