Winter Clinic

Winter Basketball Clinic

For Players who want to get some extra practice during winter break!

WHEN: Monday, December 30th
WHERE: Big Valley Christian High School
(1020 Pelandale Ave - Modesto)
GRADES: 2nd - 8th
TIME: 9am - 12pm
COST: $30
(+$2 online service charge)

Sign up early as space is limited

Winter Basketball Clinic

Player Information

* Indicates required field

Name *

First

Last

Players Birthday (ex. 01/23/2005) *

Gender *

Height (ft) (in) *

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

School *

Grade Level *

Player Experience *

Never Played League Baskeball Played 1 Year Played Multiple Years Played Multiple Years + Travel Ball

Parent/Guardian of Player INformation

Name *

First

Last

Name of Person Making Payment (Even if same name as above) *

To ensure there is an accurate payment record - We ask that if you or someone else is paying the fees for Summer Camp that it be indicated in the above box. This allows for Modesto Slam-n-Jam to keep accurate records for the season. Thank you for your understanding and cooperation.

Primary Phone *

Secondary Phone *

Email *

Medical Information

Insurance Company *

Name of Policy Holder *

Policy Number *

Present Health of Player *

Medications (Enter N/A if none) *

Allergies and/or Drug Sensitivities (Enter N/A if none) *

Past Health /Injuries (Enter N/A if none) *

Consent for Medical Treatment for a minor:

As a parent or legal guardian of the above player. I hereby authorize the directors of MSNJ to use their best judgement in any emergency requiring medical attention. I hereby waive and release MSNJ from all liabilities. I will be responsible for any medical or other charges in connection for my son or daughter.

Participation Consent:

I, the parent/guardian of the above player agree that I will promote good sportsmanship by modeling positive behaviors in the MSNJ event facility. This is in regards to officials, players, coaches, fans, and MSNJ staff. If I have a concern I will take it to the MSNJ Director.

Photo/Video/Audio Consent & Waiver:

MSNJ requests the rights to use all photos, videos, and/or audio clips of players and adults engaged in the participation of a MSNJ event. These may be used for a promotional brochure, our website, local newspaper and other purposes. I hereby forfeit any rights to claims for payments/royalties.

By signing below (provide a check in the YES box), I confirm that I understand and agree to the above requests and conditions. I confirm by checking the box below that I am at least 18 years old and the parent/guardian responsible for the player above.

I/We agree with the above. *

Yes

Once this form is submitted you will be directed to the Payment page.

Submit

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