Elite College Exposure Application
this is for individual players, not teams- for boys and girls                    
                                April 1, 2012 at  Penn State Harrisburg University
777 West Harrisburg Pike
Middletown, PA  17057

 

Name _______________________________________   Address _______________________________________

City _______________________________              State ________        Zip code   ___________

Email address  _______________________   Home phone ____________________    Birth date ____________

Height _______  Weight ______    Graduating (circle one)   2012    ---  2 013   ---  2014   ---  2015       

High School ______________________________________     _______Male          _______Female

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 Shootout and the host school do 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 _____________

Print this form, fill it out, and mail it.
   Players in grades 9, 10, 11. and 12 are eligible to participate.  Mail your form in early, we will only take the first 200 players to register.  Our fall shootout was sold out before the event.
Check one:
____________ $115.00  Boys Shootout,  early registration, to Mar16
____________ $115.00  Girls Shootout,  early registration, to Mar 16
___________   $130 Late registration fee,  Boys Mar 17 to the event
___________   $130 Late registration fee,  Girls Mar 17 to the event

No refunds---------------------Make your check payable to: Bill Gaffey
and mail to:      Basketball Shootouts,  c/o Bill Gaffey    417 Bolton Drive, Harrisburg, PA   17112          
                             call 717-545-0872------email pahoops@verizon.net

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Shootout Directions HERE                                                          Hotels for Shootout    HERE