2011-2012 Basketball Stars of America Camp Registration Form

Name: _____________________________________________ Date of Birth: _________

Home Street Address: _________________________________________________

City: _________________________________________ State: __________ Zip: ______

Age: _________ Grade: _________ School: ___________________________________

Height: __________ Primary Position: ________ Shirt Size: __________ Sex: Male/Female

Cell Phone Numbers: ____________________________________________________

Home Phone: _______________________________________________________

Email: __________________________________________________________


Waiver:
I understand that I am enrolling my child in the Basketball Stars of America Program or affiliated program and that the Basketball Stars of America and any affiliates, Coach Daryn Freedman, Hoop Mountain PA, Sewickley Academy or any coaches or facilities used will not be liable for any injuries incurred during participation in the program. I also understand that there are no refunds! If a player is injured and can't continue, he or she will receive a prorated credit towards another BSA or affiliated program.
Signature of Parent/Guardian: : ____________________________________ Date: _______

Programs: Please check all attending:

Basketball Camps at Hillcrest Christian Academy:
____ Winter Break Basketball Camp - $175 for all 4 days
____ Winter Break Camp by The Day @ $50/day - Days: ____________________
____ MLK Day Mini Camp (January 16, 2012) - $50


Please mail completed registration form along with a check made out to: Basketball Stars of America LLC

To: Basketball Stars of America LLC, c/o Coach Daryn Freedman, 547 Burkes Drive, Coraopolis, PA 15108