at Spooky Nook Sports
is for individual players, not teams-
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 ____
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 email@example.com
mail to: bill gaffey, 417 Bolton drive, harrisburg pa 17112