"The Big 60 "-Elite College Exposure Application-"The Big 60 "
Oct 11 at Lancaster Bible College
(901 Eden Rd, Lancaster, PA 17601)
this is for individual players,
First Name ____________________________Last
Name ________________________________ Gender _______
City _______________________________ State ________ Zip code ___________
Print email address _______________________ Home phone ____________________ Birth date ____________
Height _______ Weight
Graduation year (circle one) ____2016 ____2017 ___2018
High School ______________________________________ city__________________________________ state ______
Parent Consent and Medical Information
(Players cannot participate unless they have medical insurance).-Players cannot participate unless this section has been completed and signed by the parent or guardian. I understand that the Showcase and the host venue does not carry medical or accident insurance for the participants, and I hereby certify that my child is covered by personal insurance or is included in a policy which I have in place. I authorize routine medical care for my child by the Shootout trainer. I further authorize any treatment considered routine to be referred to a local physician or to an emergency room at my expense. I further authorize and provide my consent and permission for my child to participate in this event.
Insurance Company ____________________ Policy _____________ Group # ________
Name of Policy Holder _____________________________ Home Phone __________
Signature of parent/guardian _________________________ Cell phone _____________
Payment choices (No
Refunds) Check one:
____check ____ money
order ____ credit card on
___________ For Oct 11- $125.00 Boys Shootout, early registration- at Lancaster Bible College- late registration Sept 27 to day of the event $140.00.
___________ For Oct 11- $125.00 Girls Shootout, early registration- at Lancaster Bible College-late registration Sept 27 to day of the event $140.00.
Oct 25- $125.00 Boys Shootout,
early registration at Spooky Nook, late
registration Oct 11 to day of the event $140.00.
___________ For Oct 25-$125.00 Girls Shootout, early registration at Spooky Nook, late registration Oct 11 to day of the event $140.00.
Send your check or money order with your application (Make your check payable to: Bill Gaffey,) or pay by credit card on Pay Pal and send your completed application.
To pay by credit card on Pay Pal, click on the button, "Buy Now" (Make your payments payable to: Bill Gaffey, you don't need a Pay Pal account to make your payment) Denote who the payment is for!!
and mail to: Bill Gaffey 417 Bolton Drive, Harrisburg, PA 17112
call 717-545-0872------email firstname.lastname@example.org