Bathurst Minor Basketball Association
2016 – 2017 Registration Form
PLAYER INFORMATION
Male
Female
Player’s Name:__________________________
City: _______________________________
Address:_______________________________
Parent/Guardian: _____________________
Postal Code:____________________________
Cell Number:__________________
Home Phone Number: ___________________
School Attending:_____________________
Medicare Number: ______________________
E – Mail: ___________________________
Birth Date: ___DAY _____MONTH____YEAR
DIVISION
Jr.Puppy (2011– 2012)
Puppy (2009– 2010)
Jr.Mini (2007– 2008)
FEES
__________
# of Players in family
1 Player
$90
__________
2nd Player
$60
__________
Any add. Children
$30
__________
st
Mini (2005 – 2006)
Bantam (2003 – 2004)
Midget/Juvenile(1999– 2002)
OFFICE USE
Cash:
Cheque:
Rec’d By:
___________________
___________________
___________________
No Refunds after October 30th 2016
*** There will be an additional fee
of 50$ for those individuals playing
for a REP team***
Total
_____________
WAIVER
I hereby waive and release the Bathurst Minor Basketball Association, its agents, representatives, coaches and
officials from any claim or action for any injury received by my child in coming, going, or during Association
activities.
CONSENT
I hereby give permission for the Bathurst Minor Basketball Association to use photographs taken of my child
during league games and practices on the Bathurst Minor Basketball website and BMB controlled social media
sites. Photos, which will not identify players, will only be used to publicize basketball in the Chaleur region and
will not be sold or otherwise used for any other purpose.
Date: _______________________ Signature of Parent/Guardian: ________________________________