basketball academy basketball

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L L A B T E K BAS Y M E D A C A

REGISTRATION FORM Enrollment is first-come, first served. * Notes Required Field

Player First Name * _____________________________ Player Last Name * _____________________________ Email address _________________________________ Grade (Fall 2017) * _________ T-Shirt Size: _________ T-shirt availability and sizing cannot be guaranteed.

Choose Camp or Camps Attending: Fundamentals Camp 5th - 10th grade boys and girls Cost: $145 Boys Shooting Camp 7th - 12th grade boys Cost: $95 For Session Dates & Times, visit pivotalbasketball.com/camps Attend all sessions or as your schedule permits. Due to facility court rental fees and insurance, no discounts or refunds will be available for missed sessions.

Emergency Contact Information Parent First Name * ____________________________ Parent Last Name * ____________________________ All Session Held At: Round Rock Sports Center Email address * _______________________________ 2400 Chisholm Trail Emergency Cell Number * ______________________ Round Rock TX 78681 Allergies * YES NO If YES, Please list allergies: ___________________________________________________________ Medical Release: I hereby authorize Pivotal Basketball, LLC, its coaches and/or staff to act for me in according to his/her best judgment in any emergency requiring medical attention. I hereby hold harmless, release, and forever discharge Pivotal Basketball, LLC or its representatives and employees from all claims, demands, and causes of action which I, my child, representatives, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization or from actions resulting from participation in Pivotal Basketball camps or sessions. Photo Release: I additionally grant Pivotal Basketball, LLC, its representatives and employees permission to use the likeness of my child in a marketing photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications for any lawful purpose, without payment, name, or other consideration. Parent Signature * ___________________________________

Date * ______________________

Make checks payable to: Pivotal Basketball, LLC Mail to: Christian Mueller, 129 Cibolo Ridge Drive, Georgetown, TX 78628