"The Big 60 "-Elite College Exposure Application- October 16,  2016

Oct 16 at Spooky Nook Sports (Manheim, PA)
-separate  divisions: one for boys and one for girls

Players in grades  9, 10, 11. and 12 are eligible to participate.  Mail your form in early.   
 Players will be accepted on a first come basis.

this is for individual players, not teams-
All games live streamed
& all games placed on YOUtube

Boys-Registration or Girls-Registration
-Check the posted schedule two days before the event on http://www.pahoops.org/
-event runs 8:30 am to 4:00 pm

First Name ____________________________Last Name ________________________________ Gender  _______

Address _______________________________________                                                     Birth date ____________

City _______________________________              State ________        Zip code   ___________

Print email address  _______________________   Home phone ____________________   

Height _______  Weight ______Graduation year (circle one)  ____2017   ___2018   ____2019____2020

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 not 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 - Check one:  ____check   ____ money order  

___________   For Oct 16-  $128.00  Boys Shootout,  early registration at Spooky Nook.   Late registration $140.00 Oct 8th  until the event.
___________   For Oct 16-  $128.00  Girls Shootout,  early registration at Spooky Nook.   Late registration $140.00 Oct 8th until the event.

Payment choices (No Refunds in the week prior to the event) Check one:  ____check   ____ money order  ____ credit card on Pay Pal 
Send your check or money order with your application (Make your check payable to: Bill Gaffey,) 

Send your check or money order with your application (Make your check payable to: Bill Gaffey).  
For Pay Pal,
click on the "BUY NOW" button, then enter the amount you are paying in the "Price Per Item" box.

and mail to:  Bill Gaffey    417 Bolton Drive, Harrisburg, PA   17112
call 717-545-0872------email wgaffey@pa.net

mail to: bill gaffey,   417 Bolton drive,  harrisburg pa 17112

email  wgaffey@pa.net